Hand And Upper Extremity Reconstruction

PROCEDURES IN RECONSTRUCTIVE SURGERY Series Editor: Gregory R.D. Evans MD FACS General Reconstructive Surgery Gregory R...

Author: Kevin C. Chung MD MS

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PROCEDURES IN RECONSTRUCTIVE SURGERY Series Editor: Gregory R.D. Evans MD FACS General Reconstructive Surgery Gregory R.D. Evans MD FACS and Garret A. Wirth MD ISBN: 978-0-7020-2925-7

Head and Neck Reconstruction Charles E. Butler MD FACS ISBN: 978-0-7020-2926-4

Hand and Upper Extremity Reconstruction Kevin C. Chung MD MS ISBN: 978-0-7020-2916-5

Cosmetic and Reconstructive Breast Surgery Maurice Nahabedian MD FACS ISBN: 978-0-7020-2915-8

An imprint of Elsevier Limited © 2009, Elsevier Limited. All rights reserved. Figures 19.1–9 © David J. Slutsky MD No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior permission of the Publishers. Permissions may be sought directly from Elsevier’s Health Sciences Rights Department, 1600 John F. Kennedy Boulevard, Suite 1800, Philadelphia, PA 19103-2899, USA: phone: (+1) 215 239 3804; fax: (+1) 215 239 3805; or, e-mail: [email protected]. You may also complete your request on-line via the Elsevier homepage (http://www.elsevier.com), by selecting ‘Support and contact’ and then ‘Copyright and Permission’. First published 2009 ISBN: 978-0-7020-2916-5

British Library Cataloguing in Publication Data A catalogue record for this book is available from the British Library Hand and upper extremity reconstruction. – (Procedures in reconstructive surgery series) 1. Surgery, Plastic 2. Hand – Surgery 3. Arm – Surgery I. Chung, Kevin C. 617.5′750592 ISBN-13: 9780702029165

Library of Congress Cataloging in Publication Data A catalog record for this book is available from the Library of Congress

Notice Neither the Publisher nor the Editors assume any responsibility for any loss or injury and/or damage to persons or property arising out of or related to any use of the material contained in this book. It is the responsibility of the treating practitioner, relying on independent expertise and knowledge of the patient, to determine the best treatment and method of application for the patient. The Publisher

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SERIES PREFACE When I was studying for my Plastic Surgery Oral Boards and during my training, I was struck by the lack of a book that would explain common procedures in plastic surgery for specific problems. This is probably due to the unique and creative drive of our specialty and its emphasis on multiple approaches. Spurred by this seeming lack of a one volume book to carry to the operating room or utilize for studying, we produced an atlas for plastic surgery that would focus of common approaches to commonly seen problems. Now eight years later, the continued interest in such a book has produced this four volume set. The purpose of these volumes is to allow the student, resident or plastic surgeon to read and absorb common approaches to plastic

surgery problems seen routinely. It is our hope that the procedures discussed in these volumes will allow quick in depth approaches, proposing common indications, surgical techniques, postoperative care and avoidance of pitfalls for common surgical problems. The student, resident or plastic surgeon should be able to utilize each of these volumes as a quick and easy access to treatment options for their patients. It is our desire that these volumes will become as popular as our first volume eight years ago and that a new generation of plastic surgeons will use, benefit and enjoy the books for years to come. G.R.D.E.

vii

VOLUME PREFACE Various specialties are involved in taking care of patients with hand injuries and conditions. The purpose of this book is to provide a practical guide to the treatment of common hand problems. I have recruited an international list of authors who are established experts in this field to give a fresh perspective on the ever-changing and advancing specialty of hand surgery. This book is not meant to be a comprehensive textbook on all aspects of hand and upper limb surgery, but an economical and richly illustrated textbook that minimizes the burden on the readers by distilling the most important information. All of the chapters are carefully edited to provide the most up-to-date materials that are augmented by carefully illustrated pictures and sketches. The most innovative part of this book is comprehensive video list in the accompanying DVD. There are over 25 videos that include a scholarly discussion on the examination of the hand and wrist, as well as carefully produced videos by the editor to highlight the essence of key operations in this text. I hope that I can continue to update the DVD in future chapters to illustrate the most innovative and practical surgical procedures in this specialty.

This book could not be accomplished without my wonderful Elsevier editors based in London, England. Claire Bonnett worked tirelessly to organize all the materials in a logical sequence, and the leadership of Sue Hodgson has made this project possible. I would also like to personally acknowledge my excellent assistants, Elizabeth Petruska and Allison Pushman who organized the complexity of all facets of this major textbook into a triumphant conclusion. Most importantly, I would like to thank my colleagues in all the surgical specialties who have embraced my effort in producing this textbook to enhance the practice of hand surgery for our patients. I hope that this textbook will serve as a stimulus for other nations where hand and upper extremity surgery is in its infancy. Hand and upper limb diseases are prevalent throughout the world and our collective effort to share knowledge and expertise will fulfill our obligations as physicians and surgeons to help those in need. K.C.C.

DEDICATION To Chin-Yin and William

ix

CONTRIBUTORS

Roberto Adani, MD Chief of Hand Surgery Unit Policlinico G.B. Rossi University of Verona Verona Italy Brent Bickel, MD MetroHealth Columbus, OH USA Reuben A. Bueno, Jr., MD Assistant Professor The Plastic Surgery Institute Southern Illinois University School of Medicine Springfield, IL USA Riccardo Busa, MD Consultant of Hand Surgery Hand Surgery and Microsurgery Unit University of Modena and Reggio Emilia Modena Italy Peter Carter, MD Department of Orthopaedic Surgery UT Southwestern Medical Center at Dallas Dallas, TX USA Victor W.T. Chee, MBChB, MMed, FAMS Director, Regional Anaesthesia Program Tan Tock Seng Hospital Singapore Neal Chen, MD Hand and Microvascular Fellow MGH Orthopaedic Hand and Upper Extremity Service Boston, MA USA Winston Chew, MBBS, MMed, FRCS Senior Consultant Orthopaedic Surgeon; Chief of Hand Service Department of Orthopaedic Surgery Tan Tock Seng Hospital Singapore

Kevin C. Chung, MD, MS Professor of Surgery Section of Plastic Surgery Department of Surgery Assistant Dean of Faculty Affairs (Institutional Track) University of Michigan School of Medicine Ann Arbor, MI USA Scott F.M. Duncan, MD, MPH Assistant Professor of Orthopedic Surgery Mayo Health System Owatonna, MN USA Marybeth Ezaki, MD Professor Department of Orthopaedic Surgery UT Southwestern Medical Center at Dallas Dallas, TX USA Grey Giddins, BA, MD, Bch, FRCS, MR The Hand to Elbow Clinic The Bath Clinic Bath UK Robert M. Greenleaf, MD Resident Department of Orthopaedic Surgery Allegheny General Hospital Pittsburgh, PA USA Warren C. Hammert, MD Associate Professor of Orthopaedic Surgery and Plastic Surgery University of Rochester Medical Center Rochester, NY USA Harry A. Hoyen, MD MetroHealth West Park Medical Building Cleveland, OH USA

Thomas B. Hughes, MD Department of Orthopaedics Division of Hand & Upper-Extremity Surgery Allegheny General Hospital Pittsburgh, PA USA C. Scott Hultman, MD, FACS Chief and Program Director Ethel F. and James A. Valone Distinguished Professor of Surgery Division of Plastic Surgery University of North Carolina Chapel Hill, NC USA Jesse B. Jupiter, MD Hansjorg Wyss Professor of Orthopaedic Surgery Harvard Medical School; Chief, MGH Orthopaedic Hand and Upper Extremity Service Massachusetts General Hospital Boston, MA USA Loree Kallianinen, MD, FACS Assistant Professor Department of Plastic and Hand Surgery The University of Minnesota Regions Hospital St. Paul, MN USA Kenji Kawamura, MD, PhD Assistant Professor Department of Emergency and Critical Care Medicine Nara Medical University Nara Japan Michael W. Keith, MD Chief of Hand Surgery Service MetroHealth Medical Center; Professor of Orthopaedics and Biomedical Engineering Case Western Reserve University School of Medicine Cleveland, OH USA

xi

xii Contributors Ilana J. Langdon, MBChB, MSc, FRCS Consultant Orthopaedic Surgeon The Hand to Elbow Clinic The Bath Clinic Bath UK Tatsuya Masuko, MD, PhD Assistant Professor Department of Orthopaedic Surgery Hokkaido University Graduate School of Medicine Sapporo Japan Akio Minami, MD, PhD Professor and Chairman Department of Orthopaedic Surgery Hokkaido University Graduate School of Medicine Sapporo Japan Takaya Mizuseki, MD, PhD Chairman, Medical Center; Chief, Hand Service Hiroshima Prefectural Rehabilitation Center Hiroshima Japan David P. Moss, MD Associate Washington Orthopaedics and Sports Medicine; Clinical Instructor Department of Orthopaedic Surgery The George Washington University Medical Center Washington, DC USA Chai Mudgal, MD Instructor of Orthopaedic Surgery Harvard Medical School; Orthopaedic Hand and Upper Extremity Service Massachusetts General Hospital Boston, MA USA

Scott N. Oishi, MD Hand Surgeon Texas Scottish Rite Hospital for Children; Clinical Assistant Professor Department of Plastic Surgery UT Southwestern School of Medicine Charles E. Seay, Jr. Hand Center Dallas, TX USA Kevin J. Renfree, MD Department of Orthopedics Mayo Clinic Arizona Scottsdale, AZ USA David Ring, MD, PhD Assistant Professor of Orthopaedic Surgery Harvard Medical School Massachusetts General Hospital Boston, MA USA Erika Davis Sears, MD House Officer Department of Plastic Surgery University of Michigan Hand Center Ann Arbor, MI USA Keith A. Segalman, MD Attending Physician The Curtis National Hand Center; Assistant Professor of Orthopedic Surgery Johns Hopkins University Baltimore, MD USA David B. Shapiro, MD Hand Surgeon Cleveland, OH USA

David J. Slutsky MD, FRCS(C) Associate Professor of Orthopedics David Geffen UCLA School of Medicine Torrance, CA USA Thomas H. Tung, MD Assistant Professor of Surgery Division of Plastic and Reconstructive Surgery Washington University School of Medicine St. Louis, MO USA Sang-Hyun Woo, MD, PhD President Woo’s Institute for Hand & Reconstructive Microsurgery W Hospital Daegu South Korea Lynda Yang, MD, PhD Assistant Professor Department of Neurosurgery The University of Michigan Ann Arbor, MI USA Elvin G. Zook, MD Professor Emeritus The Plastic Surgery Institute Southern Illinois University School of Medicine Springfield, IL USA

CHAPTER

Anesthesia for Hand Surgery

1

Winston Chew and Victor Chee

Hand surgery is highly amenable to the use of various regional techniques for the provision of prolonged anesthesia in the distal limb. This chapter describes the practical regional anesthesia approaches that the hand surgeon can use independently to provide anesthesia in the surgical field for operative intervention. The use of distal regional anesthesia has many advantages for hand surgery (Table 1.1). As with all regional techniques, success with regional anesthesia for hand surgery requires due consideration to the following points and not solely the instillation of local anesthetics at the various sites.

PATIENT FACTORS ● ● ● ●

Comorbid conditions such as pre-existing neuropathy Anxiety Inability to keep still Patient refusal

SURGICAL FACTORS Duration of surgery Duration and location of tourniquet use ● Surgery outside the area of the hand If patient and surgical factors cannot be addressed by distal regional anesthesia and judicious sedation, then the service of the anesthesiologist is required to provide surgical anesthesia using proximal brachial plexus blockade or general anesthesia. The contraindications for distal peripheral nerve blocks are listed in Table 1.2. ● ●

PERIOPERATIVE MANAGEMENT If distal regional techniques are selected for use in hand surgery, communication between surgeon and patient is

paramount. Preoperative patient selection and preparation provide the foundations for success using these techniques. This will involve a detailed explanation of the regional anesthetic procedure (number and site of injections), what to expect during surgery (as the patient is likely to be awake), what alternative measures are available should the patient feel discomfort or pain, and informed consent. Management of these expectations will contribute to the patient having a positive perioperative experience with distal regional anesthesia. Preanesthetic sedation may be required to provide anxiolysis as well as to improve regional block tolerance. This can be achieved with a combination of drugs such as benzodiazepines, narcotics and anticholinergics, depending on the preferences of the individual surgeon. In our practice, baseline assessments are made once the patient arrives, and include blood pressure measurement and pulse oximetry on room air. An intravenous cannula is inserted in the non-operative arm and sedation achieved using small doses of intravenous midazolam (0.5–1 mg boluses titrated to effect). Most patients do not need more than 5 mg. The endpoint for sedation is an awake, cooperative patient who is calm, responsive to normal verbal stimulation, and does not require airway control or respiratory and cardiovascular support. Some patients may require narcotics if there is pain due to hand trauma. For these patients we normally use fentanyl 0.5–1 μg/kg boluses titrated to effect. It is good practice to be mindful that drug combinations for sedation tend to act synergistically when administered together, and their effects may be more than what is expected when given individually. During the procedure, periodic blood pressure measurements are recorded together with continuous electrocardiogram and pulse oximetry monitoring. This practice is especially critical when using intravenous regional anesthesia (IVRA; Bier’s block), which requires the use of high doses of local anesthetics.

1

2 Hand and Upper Extremity Reconstruction TABLE 1.1

TABLE 1.2 Contraindications for peripheral nerve blocks

Advantages of distal regional anesthesia

Advantages of proximal regional anesthesia and general anesthesia

Easily performed by surgeon

Area of anesthesia may involve whole upper limb or in the case of general anesthesia, the whole body

Minimal physiological disturbance

Tourniquet well tolerated

Area of anesthesia/analgesia confined largely to hand

Can be used for prolonged surgery

Does not require patient to fast

Tolerated well by most patients

Can be safely performed on an outpatient basis

Does not require patient cooperation intraoperatively

Absolute

Relative

Patient refusal

Preexisting neuropathy

Known allergy to local anesthetic agent

Coagulopathy

Infection at site of injection

Prolonged surgery especially involving proximal tourniquet is used

Tumor surgery

Fast onset

Reduced side effects associated with general anesthesia such as nausea and vomiting No prolonged paralysis of proximal upper limb musculature associated with proximal brachial plexus blockade Can be used for prolonged analgesia techniques via catheters in the forearm

Local anesthetic

Relative potency

Procaine Chloroprocaine Prilocaine Lidocaine Mepivacaine Ropivacaine Bupivacaine LevoBupivacaine Tetracaine

1 1 2 2 2 8 8 8 8

Slow onset

Short duration

Long duration

FIGURE 1.1 Properties of commonly used local anesthetics.

Speed of onset One must remember that a successfully administered distal regional anesthetic does not equate to good surgical operating conditions and patient comfort. Attention must also be paid to the other aspects of patient care, such as body positioning, tourniquet use, preoperative emptying of the bladder, and constant communication with the patient regarding activities, to ensure immobility and tolerance during the procedure.

The speed of onset of the various local anesthetics is thought to be dependent on the aqueous diffusion rate of the anesthetic, which is inversely proportional to its molecular weight.3 Even though increased lipid solubility and high pKa are generally believed to delay onset of action, the fastestacting local anesthetic agents available are etidocaine, which is highly lipid soluble, and chloroprocaine, which has a pKa higher than that of other local anesthetics. Information on commonly used local anesthetics for regional anesthesia is summarized in Figure 1.1.

LOCAL ANESTHETIC PHARMACOLOGY

Additives to local anesthesia

Many local anesthetics are available for use in regional anesthesia. Biochemically they fall into two major classes, esters and amides. Clinically, knowledge of the various agents by their pharmocodynamic properties, such as potency, duration of action and speed of onset, gives practitioners more relevant information for making decisions regarding the selection of agents.

Various additives have been used with local anesthetics for regional anesthesia. Commonly used ones include epinephrine, clonidine, and alkalization with sodium bicarbonate. Clinically, the addition of epinephrine (1 : 200 000– 1 : 400 000) is commonly used to cause vasoconstriction and to serve as a marker of intravascular injection. However, in the context of distal regional anesthesia techniques, additives play only a small role and are rarely used in our practice as the amount of drugs used rarely reaches maximum limits, except when used in the context of IVRA. The use of epinephrine for nerve block for areas supplied by end arteries is also controversial. Although it is traditionally avoided in these areas, recent data suggest that its use, for example in digital blocks, is safe.4

Potency and duration of action The potency of local anesthetic agent increases with increasing molecular weight and lipid solubility.1,2 Lipid-soluble local anesthetics are also highly protein bound in blood and removed more slowly from nerve membranes.

Anesthesia for Hand Surgery 3 Alkalization is another technique commonly used by many practitioners. This usually involves the addition of 1 mL 8.4% sodium bicarbonate to each 10 mL of local anesthetic. Data suggest that this practice reduces pain on injection,5 although its effect in reducing onset time is more equivocal. In our practice, all the blocks described in this chapter are performed without additives.

such as midazolam 2–5 mg, and supportive management for cardiovascular collapse using advanced cardiac life support algorithms. There is currently great interest in the use of lipid infusions for the termination of refractory arrhythmias secondary to local anesthetic toxicity.7

Toxicity

Increasing plasma concentrations

Toxicity from local anesthetics can occur either as a result of direct neurotoxicity or of systemic toxicity. Although neurotoxicity has been demonstrated in various animal models, local anesthetics have a long history of safe clinical use and the significance of the neurotoxic potential at clinical concentrations is a topic of continued research. The systemic toxicity of local anesthetics is related to the serum concentrations achieved after drug deposition. Although many textbooks continue to recommend maximal local anesthetic doses, these data may not correlate well to humans receiving nerve blocks in clinical conditions. Peak plasma concentrations are related not only to the amount of drug used, but also to the site of injection,6 and the correlation to body weight is poor. Among the local anesthetics, dose limits for lidocaine remain important as it is a drug used commonly in IVRA. Suggested dose limits for lidocaine for use in IVRA should not exceed 4–5 mg/kg. With less potent local anesthetics such as lidocaine and mepivacaine, symptoms of toxicity are related to the progressive rise in serum plasma levels (Fig. 1.2). Prevention remains key in the avoidance of local anesthetic toxicity. Prudent strategies include the use of techniques with a low risk of intravascular injection, aspiration before injection of local anesthetics, giving small fractionated doses of local anesthetics, and constant communication during injection to elicit early signs of toxicity. Management of toxicity is directed at two main aspects: seizure control, usually with small doses of benzodiazepines

A

Cardiovascular instability and collapse Cardiac arrhythmias Seizures Somnolence Muscular twitching Nystagmus Shivering Dysphoria Tinnitus Dizziness

FIGURE 1.2 Systemic toxic effects of local anesthetics.

B FIGURE 1.3 A Equipment for IVRA. B Double pneumatic tourniquet used for IVRA.

4 Hand and Upper Extremity Reconstruction

INTRAVENOUS REGIONAL ANESTHESIA (IVRA)/BIER’S BLOCK (Fig. 1.3) Intravenous regional anesthesia was first described by August Bier in 1908 and has remained largely unchanged. Bier determined through cadaveric studies that the mechanism of action of IVRA involved both direct local anesthesia bathing local nerve endings and indirect local anesthesia through conduction block, probably due to local anesthetic transported to the substance of the nerves via the vasa nervosa.

Indications IVRA is suitable for all surgery below the level of the tourniquet. This technique is easily learnt and performed, and its limitations are due mainly to tourniquet discomfort with surgical procedures lasting more than 60 minutes. In addition, trauma at the surgical site may make this technique unsuitable because of pain associated with arm manipulation and application of the tourniquet during the exsanguination process.

Technique (Fig. 1.4) Obtain a functioning intravenous access in a non-operative limb for sedation. The intravenous catheter is inserted into the operative limb as far distally as possible. The double pneumatic tourniquet is then applied, ensuring that there is an adequate layer of soft cotton lining under it to protect soft tissues around the arm. Always carry out a pre-use check to ensure the tourniquet system is not faulty. The arm is then elevated and exsanguinated using the Esmarch compression bandage, wrapping the entire limb in a spiral fashion from the hand to the edge of the distal pneumatic tourniquet cuff. The proximal cuff is then inflated after digitally occluding the axillary artery. The tourniquet pressure is maintained at 100 mmHg above the systolic blood pressure. The Esmarch bandage is then removed. Local anesthetic solution is given via the cannula in the operative limb. After delivery of the local anesthetic solution, the intravenous cannula on the operative arm is removed and pressure applied over the site. After about 20 minutes, confirm that the operative block is successful. The distal tourniquet is then inflated and the proximal tourniquet deflated to improve tourniquet tolerance.

NERVE BLOCKS IN THE MID-FOREARM WITH ULTRASOUND GUIDANCE The courses of the median, radial and ulnar nerves in the forearm are well described and can readily be blocked for both anesthesia and analgesia. Although open cutdown techniques are widely used for placement of catheters to provide prolonged analgesia, ultrasound-guided regional anesthesia has enabled accurate and consistent success rates with percutaneous nerve blocks8 and allowed placement of catheters to provide prolonged analgesia. In the case of surgery involving the little finger the use of a single

catheter can provide sole analgesia, whereas in surgery involving other parts of the hand, multiple catheters with local anesthetic infusion can be used to meet the analgesic requirements for postoperative active therapy.

Ultrasound imaging for regional anesthesia techniques Ultrasound imaging uses high-frequency sound waves (3– 17 mHz). For mid-forearm nerve blocks a high-frequency linear probe (7.5–12 mHz) is ideal, as the target nerves are generally not more than 3 cm deep to the skin. Common nomenclature used to describe ultrasound-guided blocks include a description of the target (long axis, longitudinal view, or short axis, transverse view) and the needle approach in relation to the imaging plane (out of plane or in plane). Although combinations of long-axis, short-axis, in-plane and out-of-plane approaches can be used, we commonly use the short-axis view together with an out-of-plane needle approach for mid-forearm nerve blocks.

Equipment The equipment used for ultrasound-guided nerve blocks is shown in Figure 1.5. For single-shot techniques, normal hypodermic or short beveled nerve block needles may be used. For catheter placement, various commercial sets are available, such as the Contiplex A Set (Braun, Melsungen, Germany).

Indications Blockade of the various nerves in the forearm with ultrasound can be used instead of a wrist block for hand surgery. These techniques can also be used as rescue blocks for inadequate anesthesia or analgesia in the various nerve distributions. The main indication for nerve blocks in the forearm is to facilitate catheter placement to provide prolonged analgesia to enable painless hand therapy in the early postoperative period.

MEDIAN NERVE BLOCK (Fig. 1.6) Anatomy The median nerve leaves the cubital fossa passing between the two heads of the pronator teres. It continues distally deep to the flexor digitorum superficialis and superficial to the flexor digitorum profundus. Near the wrist, it emerges from the lateral border of the flexor digitorum superficialis and lies deep to the palmaris longus tendon.

Technique The ultrasound probe footprint for use in the sterile field is prepared with a sterile clear adhesive dressing (e.g. Tegaderm, 3M Health Care, St Paul, MN, USA) (Figs 1.7A,B). This is applied to ensure that there is no wrinkle or bubble trapped between the footprint and the dressing, as these

Anesthesia for Hand Surgery 5

A

C

B

FIGURE 1.4 A Insertion of IV catheter. B, C Application of double pneumatic tourniquet.


D

E

FIGURE 1.4, cont’d D Exsanguination using Esmarch bandage. E IV lidocaine given.

FIGURE 1.5 Equipment for ultrasound-guided nerve block. (1) Portable ultrasound machine with linear high-frequency probe. (2) Catheter introduction set. (3) Extension tubing. (4) Sterile gel. (5) Local anesthetic. (6) Syringe. (7) Sterile adhesive dressing.

will cause artifacts. Sterile jelly is also used to couple the interface between the probe footprint and the skin to improve the ultrasound image. With the forearm in a supinated position and shoulder abducted, the linear ultrasound probe is placed in the volar aspect of the mid-forearm to view the structures in the short axis (Fig. 1.7C). Here the median nerve can be easily visualized as a hyperechoeic structure with a honeycomb appearance lying in the fascial plane between the flexor digitorum superficialis and the flexor digitorum profundus (Fig. 1.8). It can be confirmed by sliding the ultrasound probe proximally and distally along the forearm to follow the course of the median nerve. Once confirmed, the target is centralized in the image and the depth of the target ascertained. A needle is then placed at the center of the ultrasound probe footprint and advanced to the appropriate depth of the target. With this out-of-plane approach the needle tip can only be visualized by tissue movements as the needle traverses the various planes. Alternatively, the needle tip can be confirmed by injection of saline and visualization of the hydrodissection plane. Once the hydrodissection is confirmed to be in the plane of the median nerve,


Cross Section of Mid Forearm Lateral

Medial

Flexor Carpi Radialis Muscle (FCR)

Palmaris Longus Muscle (PL)

Brachioradialis Muscle (B)

Flexor Digitorum Superficialis Muscle (FDS)

B

Flexor Pollicis Longus Muscle (FPL)

Median Nerve Radial Artery and Superficial Branch of Radial Nerve

A FCR

PL

Radius

C

Anterior Interosseous Artery and Nerve (branch of median nerve)

FDS Extensor Carpi Radialis Longus Muscle (ECRL)

B FCU FPL FDP

Extensor Carpi Radialis Brevis Muscle (ECRB) Abductor Pollicis Longus Muscle (APL)

APL

ECRB

Extensor Digitorum Muscle (ED)

ED

Flexor Carpi Ulnaris Muscle (FCU) Flexor Digitorum Profundus Muscle (FDP)

EPL EDM

Ulnar Nerve and Artery

ECU

Extensor Digiti Minimi Muscle (EDM)

Ulna Extensor Pollicis Longus Muscle (EPL)

Extensor Carpi Ulnaris Muscle (ECU)

A. Ultrasound Probe Placement for Superficial Radial Nerve Block B. Ultrasound Probe Placement for Superficial Median Nerve Block C. Ultrasound Probe Placement for Superficial Ulnar Nerve Block

Posterior Interosseous Artery and Nerve (deep branch of radial nerve)

FIGURE 1.6 Cross-sectional anatomy at the mid-forearm.

the syringe is switched to one with a local anesthetic and 3–4 mL of 1.5% lidocaine or 0.5% bupivacaine are deposited around the nerve under direct vision. If placement of a catheter is necessary, we use a Contiplex A set for the initial deposition of local anesthetic around the nerve and subsequently thread the catheter through the cannula distally towards the wrist, leaving not more than 5 cm of catheter in the perineural space. Postoperative infusion of 2–3 mL/h of 0.1% bupivacaine provides good analgesia in the median nerve territory.

ULNAR NERVE BLOCK

accessed for this block. The linear ultrasound probe is placed in the medial aspect of the mid-forearm to view the structures in the short axis (Fig. 1.9). Here, the ulnar nerve is easily visualized beneath the flexor carpi ulnaris as a hyperechoeic honeycomb structure. The nerve can be confirmed again by sliding the probe along the forearm and following the course of the nerve and visualizing the ulnar artery next to it on the lateral side in the distal third of the forearm (Fig. 1.10). Once confirmed, a short-axis out-of-plane approached is used for local anesthetic deposition and catheter placement, as described previously.

Anatomy

RADIAL NERVE BLOCK (SUPERFICIAL BRANCH)

The ulnar nerve passes behind the medial epicondyle of the humerus and enters the forearm by passing between the two heads of the flexor carpi ulnaris. It runs down the forearm between the flexor carpi ulnaris and the flexor digitorum profundus. In the lower third of the forearm the ulnar artery lies on the radial side of the ulnar nerve.

Anatomy

Technique With the elbow flexed 90º and the shoulder externally rotated, the medial aspect of the forearm can be easily

After piercing the lateral intermuscular septum in the lower part of the arm, the radial nerve travels into the cubital fossa lying between the brachialis on the medial side and the brachioradialis and extensor carpi radialis longus on the lateral side. At the level of the lateral epicondyle it divides into the superficial and deep branches. The superficial branch is the direct continuation of the radial nerve. It runs under the brachioradialis muscle and lies on the supinator and pronator teres muscles. In the middle third of the forearm, it travels with the radial artery beneath the bra-


A

B

FIGURE 1.7 A, B Application of sterile adhesive dressing to obtain sterile ultrasound footprint.

chioradialis before leaving the artery and passing dorsally under the tendon of the brachioradialis in the distal forearm.

Technique With the forearm in a supinated position and the shoulder abducted, the linear probe is placed on the lateral aspect of the mid-forearm to visualize the structures in the short axis (Fig. 1.11). Identification of the radial artery as a pulsating round hyperechoic structure with a hollow black center under the brachioradialis will aid in the identification of the radial nerve, which usually lies on the radial side of the artery and appears as a hyperechoeic honeycomb structure (Fig. 1.12). Once confirmed, a short-axis out-of-plane approach is used for local anesthetic deposition and catheter placement, as described previously.

WRIST BLOCK Wrist blocks are easily performed by the surgeon and are very useful for surgery of the fingers and hand. There are

five nerves that cross the wrist: three main nerves (median, ulnar and superficial radial nerves), and two cutaneous branches, the palmar cutaneous branch of the median nerve and the dorsal sensory branch of the ulnar nerve. Any of the five can be blocked according to the area of anesthesia required for the surgery. It usually takes about 15–30 minutes for the onset of anesthesia. All injections use a 27G needle where possible.

MEDIAN NERVE BLOCK Anatomy In the forearm, the median nerve passes under the flexor digitorum superficialis and emerges from the muscle on the radial aspect in the distal forearm beneath the palmaris longus tendon. Continuing distally, it then comes to lie between the palmaris longus and the flexor carpi radialis tendons, being partially covered by the palmaris longus tendon just before entering the carpal tunnel. The palmar cutaneous nerve branches from the median nerve a few centimeters proximal to the carpal tunnel, on the radial aspect of the nerve. It continues distally on the


C FIGURE 1.7, cont’d C Ultrasound-guided median nerve block.

FIGURE 1.9 Ultrasound-guided ulnar nerve block.

FIGURE 1.8 Ultrasound image of median nerve. FIGURE 1.10 Ultrasound image of ulnar nerve. FCU, flexor carpi ulnaris; FDS, flexor digitorum superficialis; FDP, flexor digitorum profundis.


FIGURE 1.12 Ultrasound image of superficial branch of radial nerve. ECRL, extensor carpi radialis longus; FCR, flexor carpi radialis.

If anesthesia over the thenar eminence is desired, the palmar cutaneous nerve can be blocked at the same time. The flexor carpi radialis tendon is identified at the wrist crease. About 2 mL of anesthetic is infiltrated over the ulnar aspect of the tendon in the subcutaneous plane. This can be approached without withdrawing the needle fully after a median nerve block.

ULNAR NERVE BLOCK Anatomy FIGURE 1.11 Ultrasound guided radial nerve block.

ulnar aspect of the flexor carpi radialis tendon before becoming subcutaneous at the level of the wrist and branching to supply the skin over the thenar eminence.

Technique (Figs. 1.13A–D, 1.16) With the hand in the supine position, the palmaris longus and the flexor carpi radialis tendons are identified. The needle is introduced from the ulnar side of the palmaris longus, directing it at about 45º towards the index finger. Alternatively, the needle may be introduced between the palmaris longus and the flexor carpi radialis, directing towards the ring finger.9 There is a higher risk of actual needle-to-nerve contact with this technique, which may be extremely painful for the patient. It is not necessary to elicit paresthesia. Another alternative technique is to inject directly into the carpal tunnel using a more ulnar approach.9 Once the deep fascia is penetrated (usually about 1– 1.5 cm deep), observe the bulge deep to the fascia as the anesthetic is injected (usually about 5 mL). There should not be a subcutaneous wheal, which indicates that the injection is too superficial.

In the distal forearm the ulnar nerve lies deep and radial to the flexor carpi ulnaris tendon. The ulnar artery lies radial to the ulnar nerve at this level. The ulnar nerve then enters Guyon’s canal before branching into the superficial and deep branches. The dorsal sensory branch of the ulnar nerve is given off a few centimeters proximal to the wrist and travels along the volar aspect of the ulna before winding around the ulnar styloid tip towards the dorsal ulnar aspect of the hand in the subcutaneous plane.

Technique (Figs. 1.14A–D, 1.16) With the hand supine, the flexor carpi ulnaris tendon is identified just proximal to the pisiform. Introduce the needle in a horizontal plane just under the tendon until the tip of the needle is just at its radial border, usually 1–1.5 cm deep. An alternative technique is to introduce the needle from the volar aspect, just radial to the tendon to a depth of about 1–1.5 cm. Observe a deep swelling of the tissues as about 5 mL of anesthetic are injected. Evidence of a subcutaneous wheal may suggest the deposition of local anesthetic in an inappropriate plane, increasing the risk of block failure. If anesthesia of the dorsoulnar aspect of the hand is required, the dorsal sensory branch of the ulnar nerve needs to be blocked. The ulnar styloid is identified with the wrist


A

B

C

D

FIGURE 1.13 A Identification of the palmaris longus. B Approach to median nerve. C alternative approach to median nerve. D Blocking the palmar cutaneous nerve.

resting over the chest or vertically. About 2–3 mL of anesthetic are infiltrated transversely around the level of the ulnar styloid in the subcutaneous plane. This can be done through the same needle puncture as the ulnar nerve block, but redirecting the needle dorsally.

RADIAL NERVE BLOCK Anatomy At the distal forearm the superficial branch of the radial nerve emerges from beneath the brachioradialis tendon, passing dorsally to come to lie in the subcutaneous plane. It travels towards the anatomical snuffbox, usually dividing into two or more branches at the distal aspect of the radius.

Technique (Fig. 1.15) With the forearm in neutral rotation, the radial styloid and anatomical snuffbox are identified. The needle is introduced at the level of the styloid transversely, infiltrating about 3 mL of anesthetic in a ring around the radial aspect of the wrist in the subcutaneous plane.

DIGITAL BLOCK Digital blocks are very useful for surgery involving the digits only. It is easy to administer and effective. Surgery can be performed using a finger tourniquet and is usually well tolerated by the patient. For all digital blocks, a small, 27G needle is usually used. Due consideration should be given to the risks versus the benefits of digital blocks in patients with peripheral vascular disease, because these blocks may compromise digital circulation. In these patients, wrist and mid-forearm blocks are preferred. Many techniques for digital blocks have been described. The ones described here represent those used commonly in our practice, in order of preference (Fig. 1.20).

Anatomy There are four digital nerves, two volar, which give out two dorsal branches at the base of the digits.

Dorsal double injection The whole digit can be adequately blocked, including the base of the dorsal aspect of the digit. However, this has the disadvantage of requiring two injections.


A

B D

C

Technique (Fig. 1.17A–E) The needle is inserted from the dorsal of the base of the digit to be blocked, starting on either the radial or the ulnar side at the level of the web space. Once in the subcutaneous layer, about 1 mL of local anesthetic is infiltrated, raising a wheal. The needle is then passed from the dorsal to the volar direction until it starts to tent the volar skin. This can be palpated with the surgeon’s index finger. The needle is then withdrawn about 1–2 mm and aspirated to avoid an intra-arterial injection; 1–2 mL of anesthetic are then infiltrated. A bulge on the volar aspect of the digit can be seen

FIGURE 1.14 A Identification of the flexor carpi ulnaris (FCU) tendon. B Introduction of the needle horizontally. C Alternative approach to the ulnar nerve. E Blocking the dorsal sensory branch.

and felt. The process is then repeated for the opposite side of the digit.

Variations in technique

1. To reduce the pain from the second injection, redirect the needle and infiltrate the skin across the dorsal aspect of the finger without withdrawing the needle completely after the first injection. The second injection on the other side of the digit will then be through anesthetized dorsal skin.

Anesthesia for Hand Surgery 13 2. Directing the needle into the web space proximally will result in blockade of the common digital nerve as it branches at the intermetacarpal region.10

Single volar injection A single subcutaneous injection of local anesthetic at the level of the A1 pulley or metacarpal head is sufficient to block the whole digit. The advantage of this over the double dorsal injection technique is that only one injection is required. However, the dorsal area over the base of the proximal phalanx may not be blocked adequately. It is also more painful, as volar skin is more sensitive.

directed at about 45º distally. About 3 mL of local anesthetic are injected (Fig. 1.18). If anesthesia of the dorsal skin over the proximal phalanx is required, a supplementary dorsal injection is required.

Variations in technique 1. Direct the injection towards two sides of the flexor tendon to infiltrate the anesthetic more directly over the digital nerves.9,10 2. Injection through the proximal digital crease.11 This is reported to be less painful.

TRANSTHECAL BLOCK (Fig. 1.19)

Technique At the level of the distal palmar crease, the needle is inserted into the subcutaneous plane in line with the flexor sheath,

FIGURE 1.15 Blocking the superficial radial nerve.

Since Chiu12 first reported the use of the transthecal technique of digital block in 1990, there has been a surge of interest, and it has been used successfully by many surgeons.13,14 An injection of local anesthetic into the flexor sheath provides rapid onset in the whole digit. In the cadaveric work by Sarhdi and Shaw-Dunn,15 it was shown that the solution injected intrathecally escapes from the flexor sheath around the vincular vessels into the perivascular loose areolar tissue. This occurs at the base and head of the proximal phalanx. The solution then spreads along the main digital nerve and vessels, and their volar and dorsal branches. The advantages of this technique are that only a single injection is required, onset of anesthesia is rapid, the risk of injuring the neurovascular bundle is minimal, and only a small amount of anesthetic is required, usually 2 mL. Owing to the extension of the flexor sheath to the wrist, the thumb and little finger require more volume, up to 4 mL.16 However, this may be overcome by applying digital pressure just proximal to the site of injection.12 The main

C Palmaris longus tendon B Flexor carpi ulnaris muscle

A

Median nerve Flexor carpi radialis tendon

Ulnar nerve

D

Ulnar

Radius

FIGURE 1.16 Summary of techniques of nerve blocks at the wrist. Median nerve block: A between flexor carpi radialis (FCR) and palmaris longus (PL); B, ulnar to palmaris longus. Ulnar nerve block: C, volar approach radial to flexor carpi ulnaris (FCU), and D, under FCU.


A

B

C

D

FIGURE 1.17 A Dorsal entry point on ulnar side of digit. B Raising a subcutaneous wheal. C Palpation of the needle on the volar aspect with the index finger before withdrawing slightly and infiltrating the local anesthetic. D, E Repeating the process on the radial side.

E

Anesthesia for Hand Surgery 15 disadvantage is that it is more painful than subcutaneous injections.14,17–19

Technique The flexor sheath is identified by palpation at the level of the metacarpal head or A1 pulley. The needle is introduced into the sheath just proximal to the A1 pulley, directing about 45º distally. About 2–3 mL of local anesthetic are then infiltrated into the sheath. Pressure is maintained in the plunger until the anesthetic flows easily. The finger can be seen and felt to distend along the course of the flexor sheath, up to the blanching pulp.

Variations in technique (Fig. 1.19) 1. Introduce the needle into the sheath at the level of the proximal digital crease from the distal to proximal direc-

tion, at about 45º, superficial to the flexor tendons. By holding the finger with the thumb over the flexor aspect, the bulge of the tendon sheath caused by the anesthetic can be easily palpated. 2. Perpendicular insertion of the needle at the level of the proximal digital crease straight through the flexor tendons to the bone, and withdrawing the needle slowly while applying pressure to the plunger.20 3. Another method is to put the injection site midway between the proximal and middle digital creases, which is reported to be less painful.21

LOCAL INFILTRATION Local infiltration of local anesthetic is useful for minor surgery of the hand, including excision of lumps, ganglia, carpal tunnel release and trigger finger release.

Field block (Fig. 1.21) The local anesthetic is infiltrated via a needle puncture just proximal to the lump, fanning the needle out in a V-shaped direction. This will cover the proximal area. The distal half is covered by giving two more injections in a converging V direction, with the needle puncturing the anesthetized skin. For deeper structures such as ganglia, it is recommended that local anesthetic be given in the deeper planes at the level of the tendons and joint capsule. Carpal tunnel release can be performed under general anesthesia, regional anesthesia (brachial plexus block, nerve blocks at the level of the forearm, or Bier’s block) or local anesthesia. Local anesthetic is infiltrated in the subcutaneous plane over the carpal tunnel22 (Fig. 1.22) and the distal forearm just proximal to the carpal tunnel. We find that it is not necessary to give local anesthetic into the carpal tunnel,23 although it has been reported that subcutaneous

FIGURE 1.18 Single volar subcutaneous injection.

B

C

D

A

Fibrous tendon sheaths Synovial (flexor tendon) sheath Flexor digitorum profundus tendon Flexor digitorum superficialis tendon

P3

MC

P1

P2

FIGURE 1.19 Diagram of longitudinal section of finger with various approaches of needles into the tendon sheath. A Chiu;12 B Whetzel et al.;20 C Bhatti;22 D Authors’. (MC = metacarpus, P1 = proximal phalanx, P2 = middle phalanx, P3 = distal phalanx).

TABLE 1.3 Equipment for Intravenous Regional Anesthesia (IVRA) (See Figures 3A and B) • 2 Intravenous Cannula (one for delivering IVRA, the other on the non operative arm, as a functional intravenous access for sedation and emergency) • Simple tourniquet for intravenous cannulation • Esmarch bandage 60 inches in length, 4 inches wide • Soft cotton lining • Double pneumatic tourniquet systems • Standard American Society of Anesthesiologists monitors (electrocardiography, blood pressure, pulse oximeter) • Resuscitation equipment necessary for the conduct of resuscitation as per American Heart Association Advanced Cardiac Life Support guidelines. • Lidocaine ( 30–50 ml of 0.5% lidocaine or 20 ml of 1.5% lidocaine or 15 mls of 2% lidocaine)

Clinical Pearls

Success with distal regional anesthesia techniques

●

Strict patient and procedure selection

●

Anticipation and management of perioperative expectations

●

Attention to other potential areas of discomfort during procedure

Clinical Pearls

Local anesthetic drug selection

●

The effectiveness of a given local anesthetic is largely determined by the dose (mass) and site of administration.

●

Recommendations for maximal doses of local anesthetics are not directly applicable to regional anesthetic techniques except for Intravenous regional anesthesia.

Clinical Pearls ●

Short axis view with the ultrasound provides a transverse view of the nerves and is easier to identify the nerve of interest.

●

Out of plane needle approaches reduce the skin to nerve travel distance, making the acquisition of targeting skills easier.

●

Use of hydro-dissection techniques allow for visualization of the various planes of needle tip travel to confirm local anesthetic delivery around the target nerves.

●

Catheter infusion rates should be kept as low as possible to avoid leak problems in the post-operative period around the catheter insertion point.

Clinical Pearls Clinical Pearls

Intravenous Regional Anesthesia (IVRA)

●

Excellent results have also been demonstrated in hand surgery using more proximal sites of local anesthetic delivery such as the distal forearm25 or cubital fossa.26

●

For patients with trauma in operative limb, some authors have advocated the use of a third tourniquet in the forearm for preliminary induction of anesthesia in the hand before application of Esmarch30. Alternatively, effective venous drainage of the extremity can be achieved by simply elevating the arm for 5 minutes prior.

Nerve Blocks in the midforearm with ultrasound

Nerve Blocks at the wrist

1. Ensure an adequate period of time (about 15 mins) for the blocks to work. Usually the nerve blocks are given first before scrubbing for surgery. 2. The local anaesthetic should be injected slowly to reduce pain resulting from distension. 3. Avoid intra-arterial injections by aspirating before injecting.

●

●

●

Usual dose of lidocaine is approximately 3mg/kg. Systemic toxicity can occur due to leakage past the tourniquet, accidental tourniquet deflation, or intentional deflation after a brief period. Intentional intermittent cuff deflation at the end of surgery may effectively prolong the time to achieve peak arterial concentrations of the local anesthetic but may not be reliable in minimizing the toxicity due to the release of local anesthetic into the circulation. The tourniquet should not be deflated until at least 30 minutes have passed after the injection of the local anesthetic in the operative limb.

4. Avoid intra-neural injections, especially in patients under general anesthesia. Follow anatomical landmarks and ensure that the local anesthetic flows smoothly during injection without excessive force. In awake patients, paresthesia during needle introduction, or severe pain when infiltrating the anesthetic should alert the surgeon, and the needle should be repositioned. 5. Anatomical variations may result in inadequate cover for the expected area of anesthesia. Block more than one nerve if necessary, especially for median and ulnar nerves. 6. Although local pain control may be adequate, tourniquet pain limits the duration of surgery.

Clinical Pearls

Transthecal block

Clinical Pearls

Digital blocks

1. It is difficult to locate the space between the flexor tendon and the sheath. Applying steady pressure while withdrawing the needle very slowly will result in a sudden ease of injection when the needle tip is in the potential space between the sheath and the tendon. The consolation is that the digital block will still work if the local anesthetic is deposited in the subcutaneous plane.

●

Comparison of injection pain between dorsal and volar subcutaneous techniques have yielded equivocal results.28,29 Data suggest that the transthecal technique is associated with increased injection pain.17,18,30,31 In our practice, injection pain is reduced with the use of the dorsal technique, small gauge needles and slow injection rates.

2. Strict sterile technique must be adhered to, as an infection in the flexor sheath can be disastrous.

●

The dorsal technique is preferred when anesthesia over the base of the proximal phalanx is required as volar techniques may spare this area.36

●

Although recent data suggest that the use of local anesthetic with epinephrine is safe,4,32,33,34,35,36 this has not been adopted in our practice as its reported benefits (prolonged analgesia and temporary hemostatic effect) are easily achieved with other alternatives. Its use is not recommended in digits with vascular compromise.

A

Extensor tendon

Dorsal digital nerve

Base of proximal phalanx

Digital artery

Lesion

Volar digital nerve Flexor tendon sheath 3

B

4

C

FIGURE 1.20 Summary of digital block techniques. A Traditional dorsal approach. B Volar subcutaneous approach. C Transthecal approach.

2

1

FIGURE 1.21 Diagram to show infiltration of field block, from steps 1 to 4 using three punctures.

FIGURE 1.22 Subcutaneous infiltration over the carpal tunnel.

18 Hand and Upper Extremity Reconstruction infiltration alone may not be sufficient in some cases.24 For endoscopy-assisted carpal tunnel release, local infiltration, especially into the carpal tunnel, may obscure the view.

SUMMARY A summary of the procedures discussed is shown in Table 1.3. The use of regional anesthesia techniques is associated with risks common to all nerve block techniques. These include vascular/neural injury, local anesthetic toxicity, and infection. These risks can be minimized with the use of proper technique and precautions. This, coupled with the high success rates and efficacy, has resulted in the continued widespread use of regional anesthesia for hand surgery.

REFERENCES 1. Sanchez V, Arthur GR, Strichartz GR. Fundamental properties of local anesthetics. I. The dependence of lidocaine ionization and octanol: buffer partitioning on solvent and temperature. Anesth Analg 1987; 66: 159–165. 2. Strichartz GR, Sanchez V, Arthur GR, et al. Fundamental properties of local anesthetics. II. Measured octanol : buffer partition coefficients and pKa values of clinically used drugs. Anesth Analg 1990; 71: 158–170. 3. Brouneus F, Karami K, Beronius P, Sundelof L. Diffusive transport properties of some local anesthetics applicable for iontophoretic formulation of the drugs. Int J Pharm 2001; 218: 57–62. 4. Wilhelmi BJ, Blackwell SJ, Millder JH, et al. Do not use epinephrine in digital blocks: myth or truth? Plast Reconstruct Surg 2001; 107: 393–397. 5. Yiannakopoulos CK. Carpal ligament decompression under local anesthesia: the effect of lidocaine warming and alkalinisation on infiltration pain. J Hand Surg 2004; 29B: 32–34. 6. Rosenberg PH, Veering BTh, Urmey WF. Maximum recommended doses of local anesthetics: A multifactorial concept. Reg Anesth Pain Med 2004; 29: 564–575. 7. Rosenblatt MA, Abel M, Fischer GW, et al. Successful use of a 20% lipid emulsion to resuscitate a patient after a presumed bupivacaine-related cardiac arrest. Anesthesiology 2006; 105: 217–218. 8. Liebmann O, Price D, Mills C, et al. Feasibility of forearm ultrasonography-guided nerve blocks of the radial, ulnar, median nerves for hand procedures in the emergency department. Ann Emerg Med 2006; 48: 558–562. 9. Ramamurthy S, Anderson D. Anesthesia. In: Green DP, Hotchkiss RN, Pederson WC, Wolfe SW, eds. Green’s operative hand surgery, 5th edn. New York: Churchill Livingstone, 2005; 25–52. 10. Carr DB, Kwon J. Anesthesia techniques and their indications for upper limb surgery. In: Peimer CA, ed. Surgery of the hand and upper extremity. New York: McGraw-Hill, 1996; 115–139. 11. Harbison S. Transthecal digital block. Flexor tendon sheath used for anesthetic infusion. [Letter] J Hand Surg 1991; 16A: 957. 12. Chiu DTW. Transthecal digital block: flexor tendon sheath used for anesthetic infusion. J Hand Surg 1990; 15: 471–477. 13. Castellanos J, Ramfrez C, De Sena L, Bertran C. Transthecal digital block: digital anesthesia through the sheath of the flexor tendon. J Bone Joint Surg (Br) 2000; 82: 889.

14. Morrison WG. Transthecal digital block. Arch Emerg Med 1993; 10: 35–38. 15. Sarhadi NS, Shaw-Dunn J. Transthecal digital nerve block. An anatomical appraisal. J Hand Surg 1998; 23B: 490–493. 16. Chevaleraud E. Flexor sheath anesthesia. In: Saffar P, Amadio PC, Foucher G, eds. Current practice in hand surgery. London: Martin Dunitz, 1997; 1–4. 17. Brutus JP, Baeten Y, Chahidi N, et al. Single injection digital block: comparison between three techniques. Chir de la Main 2002; 21: 182–187. 18. Keramidas EG, Rodopoulou SG, Tsoutsos D, et al. Comparison of transthecal digital block and traditional digital block for anesthesia of the finger. Plast Reconstruct Surg 2004; 114: 1131–1134. 19. Hill RG Jr, Patterson JW, Parker JC, et al. Comparison of transthecal digital block and traditional digital block for anesthesia of the finger. Ann Emerg Med 1995; 25: 604–607. 20. Whetzel TP, Mabourakh S, Barkhordar R. Modified transthecal digital block. J Hand Surg 1997; 22A: 361–363. 21. Bhatti AZ. Painless method of digital block. [Letter] Plast Reconstruct Surg 2007; 119: 444–445. 22. Gale DW. Surgical decompression of the carpal tunnel using infiltrative anesthesia: description of technique. J Roy Coll Surg Edin 1991; 36: 341. 23. Altissimi M, Mancini GB. Surgical release of the median nerve under local anesthesia for carpal tunnel syndrome. J Hand Surg 1998; 13B: 395–396. 24. Patil S, Ramakrishnan M, Stothard J. Local anesthesia for carpal tunnel decompression: a comparison of two techniques. J Hand Surg 2006; 31B: 683–686,. 25. Karalezli N, Karalezli K, Iltar S, et al. Results of intravenous regional anesthesia with distal forearm application. Acta Orthop Belg 2004; 70: 401–405. 26. Blyth M, Kinninmonth A, Asante D. Bier’s block: A change of injection site. J Trauma 1995; 39: 726–728. 27. Tham CHJ, Lim BH. A modification of the technique for intravenous regional blockade for hand surgery. J Hand Surg 2000; 25: 575–577. 28. Williams JG, Lalonde DH. Randomized comparison of the singleinjection volar subcutaneous block and the two-injection dorsal block for digital anesthesia. Plast Reconstruct Surg 2006; 118: 1195–1200. 29. Yin ZG, Zhang JB, Kan SL, Wang P. A comparison of traditional digital blocks and single subcutaneous palmar injection blocks at the base of the finger and a meta-analysis of the digital block trials. J Hand Surg 2006; 31: 547–555. 30. Low CK, Vartany A, Engstrom JW, et al. Comparison of transthecal and subcutaneous single-injection digital block techniques. J Hand Surg 1997; 22A: 901–905. 31. Low CK, Wong HP, Low YP. Comparison between single injection transthecal and subcutaneous digital blocks. J Hand Surg 1997; 22B: 582–584. 32. Krunic AL, Wang LC, Soltani K, et al. Digital anesthesia with epinephrine: an old myth revisited. J Am Acad Dermatol 2004; 51: 755–759. 33. Andrades PR, Olguin FA, Calderon W. Digital blocks with or without epinephrine. Plast Reconstruct Surg 2003; 111: 1769–1770. 34. Denkler K. A comprehensive review of epinephrine in the finger: to do or not to do? Plast Reconstruct Surg 2001; 108: 114–124. 35. Sylaidis P, Logan A. Digital blocks with adrenaline. An old dogma refuted. J Hand Surg 1998; 23B: 17–19. 36. Thomson CJ, Lalonde DH, Denkler KA, Feicht AJ. A critical look at the evidence for and against elective epinephrine use in the finger. Plast Reconstruct Surg 2007; 119: 260–266.

CHAPTER

Fingernail Reconstructive Techniques

2

Reuben A. Bueno Jr and Elvin G. Zook

INTRODUCTION TO RECONSTRUCTION By virtue of its location at the most distal aspect of the digit, the perionychium – the fingertip and nail – is the most frequently injured part of the hand. Successful reconstruction addresses both the appearance and the function of the nail. A functional nail serves multiple purposes, including protection of the tip, regulation of circulation, and contribution to the sensory feedback needed for the fine motor movements of the hand.

INDICATIONS AND CONTRAINDICATIONS Nail deformity secondary to trauma is the most common indication for nail reconstruction. ● Soft tissue and bony support is necessary for optimal reconstruction. Loss of these elements in severe crush injury may prevent successful reconstruction. ● Nail absence after excision of benign neoplasm is another indication for nail reconstruction. ● Nail reconstruction after excision of malignant neoplasm is contraindicated when treatment requires amputation at the level of the PIP joint or more proximally. Defects of the nail requiring reconstruction are usually secondary to traumatic injury. Restoration of normal nail appearance is best achieved by treatment of the injured nail matrix in the acute setting. For nail deformities that present later, reconstructive techniques may be used to provide a more normal-appearing nail. Post-traumatic deformities are often a result of scarring or loss of nail matrix. Reconstruction of the nail requires replacement of the scarred nail matrix with adjacent non-scarred matrix or nail graft. These techniques can also be used in the acute setting. Excision of benign and malignant tumors involving the nail bed matrix may require techniques of nail bed repair and reconstruction that are also used in the traumatic ●

setting. Optimal treatment is dependent on a thorough understanding of the components of the perionychium (Fig. 2.1) – skin, sterile matrix, germinal matrix, eponychial fold, and distal phalanx – and their anatomical relationships with each other. In severe crush injuries in which there is inadequate bony support or soft tissue coverage, nail reconstruction may not be an option. In these situations, revision amputation may be the preferred procedure to allow the earliest return of function.

PREOPERATIVE HISTORY AND CONSIDERATIONS Traumatic injury to the perionychium is usually due to the digit being caught in a door hinge or crushed between two objects.1,2 Features of acute nail bed injury that may be present include subungal hematoma, avulsion of the nail out of the fold, lacerations or abrasions of the hyponychial and paronychial skin, laceration of the nail bed, and fracture of the distal phalanx. Nail lacerations can be described in one of four ways: simple laceration, stellate laceration, severe crush, and avulsion. In the acute setting, the status of the entire fingertip must be assessed: quality of the skin, the presence of a subungual hematoma, quality of the nail matrix, capillary refill, sensory function, flexion and extension at the distal interphalangeal (DIP) joint, and the presence of a distal phalanx fracture. There is an associated distal phalanx fracture in 50% of nail bed injuries. This type of injury should be considered an open fracture and treated as such, with irrigation and debridement, reduction of the fracture and fixation if necessary, and repair of the nail bed (Fig. 2.2).1–4 Accurate repair in the acute period increases the chance of a normal-appearing nail. Left untreated, traumatic injury to the nail matrix may result in an abnormal appearance

19


Eponychium

Nail wall Nail fold

Lunula

Hyponychium

Nail bed Ventral floor

Paronychium

Perionychium is paronychium plus nail bed

Eponychium Lunula

FIGURE 2.1 The perionychium and its associated structures.

OPERATIVE APPROACH Anatomy The ‘perionychium’ includes the following structures: nail plate, nail bed, hyponychium, eponychium and fold, and paronychium (Fig. 2.1). The proximal portion of the nail matrix is the germinal matrix. The distal portion and the undersurface of the eponychial surface is the sterile matrix. The germinal matrix produces approximately 90% of the nail, and the sterile matrix produces the remaining 10% plus the cells on the undersurface of the nail responsible for nail adherence and shine. The hyponychium is the skin distal to the nail bed, the paronychium is the skin on each side of the nail, and the eponychium is the skin over the nail fold. The nail bed is adherent to the distal phalanx. The lunula is the white arc of the nail distal to the eponychium and represents the distal aspect of the germinal matrix. The nail grows at 0.1 mm/day. New nail growth is completed in 3–4 months, and nail appearance will improve for 9–12 months.

Exposure To provide a bloodless field, use of a Penrose drain tourniquet secured by a clamp at the base of the digit is recommended. Use of a portion of a surgical glove as a tourniquet is discouraged because of the risk of leaving the tourniquet in place after repair and placement of the dressing. The dressing may then hide the tourniquet, and vascular compromise and subsequent necrosis of the finger is possible in the postoperative period. Incisions perpendicular to the eponychial fold may be necessary for adequate exposure of the germinal matrix during repair or reconstruction.

FIGURE 2.2 Nail bed injury with concomitant distal phalanx fracture. With a break in the periosteum there is communication of the distal phalanx with the outside environment. There is a risk of osteomyelitis if not treated appropriately.

of the nail. Post-traumatic nail deformities include nail non-adherence, nail remnant, split nail deformity, and hook-nail deformity. Reconstruction of the nail matrix after traumatic injury or loss should be approached with realistic expectations. Benign tumors (glomus tumor, DIP joint ganglion), and malignant tumors (squamous cell carcinoma (SCC), melanoma) can affect nail appearance. Reconstruction of the nail matrix after tumor excision will depend on the amount of nail bed excised and the amount remaining.3–6 Management of malignant tumors involving the nail bed requires an understanding of the safe level of amputation (usually to the level of the more proximal joint) and the need for sentinel node biopsy.

NAIL BED REPAIR (Figs 2.3–2.6) Sterile preparation and draping is carried out and a digital block using a maximum dose of 7 mg/kg 1% plain lidocaine is administered. The use of surgical loupes (2.5× magnification is sufficient) is recommended for the most accurate repair. A Kleinert–Kutz elevator is used to separate the nail plate from the matrix for adequate exposure of the nail bed laceration. The nail plate is cleaned and soaked in Betadine as the nail bed repair is done. If the nail plate is not available, a silicone sheet or non-adherent gauze can be used to maintain the eponychial fold after repair. Minimal debridement of the matrix is performed to preserve as much of the nail bed as possible. The laceration is repaired with 7/0 chromic sutures under loupe magnification. The cleaned nail plate can be placed back into the eponychial fold to maintain the space under the fold and to serve as a splint for a distal phalanx fracture. A figure-of-eight suture in 5/0 nylon or a simple stitch from nail to hyponychium can be used to hold the nail in place. Split-thickness injury to the nail bed does not require closure.

Fingernail Reconstructive Techniques 21

FIGURE 2.3 Laceration with nail plate present. The nail plate is cleaned and will be used later as a splint to maintain the eponychial fold.

NAIL BED RECONSTRUCTION (Figs 2.7–2.12) A defect amenable to reconstruction may be present after the excision of scar from a prior injury to the nail bed. The scar may be causing non-adherence or a split nail deformity. Small areas 5 mm can be treated with a splitthickness nail bed graft from one of the following donor sites: adjacent non-injured nail bed, nail bed from another digit, nail bed from a toe.3,6–8 The primary goal in nail reconstruction is to restore the nail matrix to permit the growth of a flat, smooth nail plate. In order to achieve this, scar may need to be excised and the nail matrix resurfaced.

FIGURE 2.4 Repair of nail bed and surrounding skin after debridement.

In reconstruction with a split-thickness nail matrix graft, the recipient and donor sites are prepared and draped in standard surgical fashion. A digital block is administered at both sites. The digit is exsanguinated, and a Penrose drain tourniquet is placed at the base. The nail bed is exposed at both recipient and donor sites, and the defect is measured. Residual scar at the recipient site is excised. A split-thickness nail bed graft to cover the defect is harvested from the sterile matrix of the second toe using a #15 scalpel. To reduce the risk of donor site nail deformity, the germinal matrix should not be used as a graft for a defect of the sterile matrix. The graft is carefully harvested by placing the blade parallel to the nail bed and taking it thinly enough so that the blade can be seen through the graft. The split-thickness graft is sutured in place using 7/0 chromic, as for a laceration repair. Reconstruction of the germinal matrix with subsequent growth requires full-thickness germinal matrix graft from a toe (preferably the second toe) to produce nail at the recipient site.9


FIGURE 2.5 Nail plate being placed back into fold.

PINCER NAIL RECONSTRUCTION (Figs 2.13–2.16) The goal of treatment is to flatten the excessive curvature of the nail and correct the ‘pinched-in’ appearance of the nail. The nail bed is exposed as previously described and stab incisions are made in the ulnar and radial fingertips. The sides of the nail bed need to be elevated from the distal phalanx using a Kleinert–Kutz elevator or fine-pointed scissors. Injury to the paronychium should be avoided as the nail bed is elevated. Subcutaneous tunnels are created on the radial and ulnar borders, and stab incisions are made on the radial and ulnar eponychium. Dermal graft or Alloderm is cut to the appropriate length and placed in the tunnel. The graft can be pulled into the tunnel, distal to proximal, with the aid of a suture to position it in the desired position. Stab incisions are closed with 6/0 nylon.

EPONYCHIAL AND HYPONYCHIAL DEFORMITIES Reconstruction of the eponychium or the hyponychium is challenging, and efforts should be made at the time of

FIGURE 2.6 Completed nail bed laceration repair.

initial repair to avoid these problems. Pterygium is the scarring of the eponychium and nail fold to the underlying nail bed, resulting in absent nail growth or a split nail deformity. Despite attempts at the initial repair to maintain the eponychial fold with the nail plate or silicone sheeting in the postoperative period, scarring of the fold and the germinal matrix, and subsequent nail deformity is a potential complication. Release of the adherent scar and placement of a silicone sheet into the nail fold to allow epithelialization of the undersurface of the fold may allow nail growth.10 Nonvascularized composite toe eponychial grafts have also been described to reconstruct the eponychium.11 Closure of a fingertip amputation with excessive tension and/or inadequate bony support of the distal phalanx leads to a hook nail deformity. The best treatment for this is avoidance. The nail matrix should not be pulled over the distal phalanx. If adequate soft tissue is present, bone loss must be replaced with bone graft to provide distal support. If adequate soft tissue is not present, or bone graft is not a good option in the acute treatment, the nail bed should be trimmed back and volar tissue advanced to cover the exposed bone.


FIGURE 2.7 Initial presentation of nail bed crush injury.

In terms of optimal reconstruction of the fingertip – including all the components of the perionychium, bony support, and restoration of the volar pulp – the best option is a microvascular second-toe transfer. Patient selection, however, is often an issue in this most technically demanding of nail reconstruction options. Patient desire, expectations, occupation and return to work, and compliance are important factors to address if this option is to be considered.

DIP JOINT GANGLION CYSTS Ganglion cysts at the DIP joint can cause nail deformity. The cysts often arise from an osteophyte at the joint, which causes ridging or grooving of the nail. Normal appearance of the nail is restored with excision of the osteophyte and drainage of the ganglion cyst through a T- or H-shaped incision over the DIP joint. Complete excision of the cyst is not required to correct the nail deformity. Debridement of the osteophyte is the more important step.10 In exposing the DIP joint, the distal insertion of the extensor tendon should be preserved to avoid an extensor lag.

FIGURE 2.8 After repair with remaining nail matrix with defect and exposed bone.

OPTIMIZING OUTCOME ●

●

●

●

●

●

The primary goal in nail reconstruction is to restore the nail matrix to permit growth of a flat, smooth nail plate. With prompt treatment of nail bed injury, subacute and chronic problems can be avoided and a more complex reconstruction may be averted. An accurate repair of the nail matrix allows the nail plate to grow out with a smooth, flat appearance. Whereas repair in the acute period provides the best chance for a normal-appearing nail, scarring at the site of injury may produce a nail deformity. Patients should be reminded of this possibility at the time of repair.8,9,12 Results of nail bed repair are adversely affected by the following factors: avulsion or crush injury of the fingertip, the presence of a distal phalanx fracture, three or more sites injured, and the need to use a silicone sheet to replace the nail.1,2,8 Late reconstruction of the nail bed is often not as successful as surgeon or patient would desire.7


FIGURE 2.9 Harvest of split nail matrix graft from toe.

FIGURE 2.11 Graft inset into defect to cover exposed bone.

●

Management plans must be individualized, and realistic expectations discussed when treating patients with nail bed injuries.

COMPLICATIONS

FIGURE 2.10 Harvested split nail matrix graft.

Complications in the acute or subacute setting include soft tissue infection, osteomyelitis of the distal phalanx, nonunion of the distal phalanx fracture, and post-traumatic stiffness and loss of motion at the DIP joint. Complications or unfavorable outcomes in the chronic setting include scarring in the sterile matrix leading to a split nail or non-adherent nail, scarring at the eponychial fold that may interfere with nail plate growth, and persistent nail growth after unsuccessful attempt at ablation. Inadequate treatment in the acute setting often leads to a nail deformity. Scarring can lead to a split nail deformity. Absence of the nail matrix can lead to detachment of the nail. Lack of support from the distal phalanx leads to a hook nail deformity. Failure to treat a nail bed laceration and concomitant distal phalanx fracture as an open fracture may result in osteomyelitis. Too much tension at the site of nail bed repair or a lack of support from the distal


FIGURE 2.12 Appearance of nail 1 year after nail matrix reconstruction using a split graft from the toe.

FIGURE 2.14 Creation of subcutaneous tunnels through stab incisions on the radial and ulnar sides.

phalanx may result in a hook nail deformity. Nail deformities are best avoided by following the principles of acute nail repair: thorough irrigation, minimal or no debridement, accurate placement of sutures to approximate nail matrix edges, minimizing tension, and covering defects with adjacent matrix or with a split nail graft. It is better to close an irregular edge than a straight edge under tension. Split nail deformity and non-adherence can be treated by excision of scar and the placement of a split-thickness nail matrix graft from the toe.

POSTOPERATIVE CARE

FIGURE 2.13 Pincer nail deformity with characteristic ‘pinched-in’ appearance.

The dressing is left on for 5–7 days and may need to be soaked in a mixture of hydrogen peroxide and water or normal saline for removal. The repaired nail is checked for signs of infection, seroma, and hematoma. Non-adherent gauze placed to maintain the eponychial fold should be removed. Any suture used to hold the nail or silicone sheet within the fold should also be removed 5–7 days after surgery. Sutures placed in the skin of the hyponychium or paronychium should be removed 10–14 days after repair.

26 Hand and Upper Extremity Reconstruction A fingertip splint that does not include the proximal interphalangeal (PIP) joint can be used for the first 3–5 weeks after injury to protect the nail bed repair and immobilize a distal phalanx fracture if present. Early movement of the PIP joint should be encouraged: the fingertip splint protects the tip and will allow PIP motion. Hypersensitivity of the tip may be present 1–3 months post injury, and desensitization exercises may be necessary to promote use of the affected digit. Repair in the acute period provides the best chance for normal appearance of the nail. The nail plate grows at approximately 0.1 mm/day or 2–3 mm/month. When the nail plate is removed for nail bed repair, new nail growth is delayed for 3–4 weeks.7 If placed back on after repair, the old nail will remain adherent for 1–3 months and then fall off as a new nail pushes out the old one.13 After nail repair, it will take approximately 12 months for the nail to achieve its final appearance. Thickening of the nail proximal to the level of injury is seen for approximately 50 days.7,8,13 Both surgeon and patient should be aware of the stages of nail growth and the characteristic appearance at different points in the healing process as the nail grows out.

CONCLUSION

FIGURE 2.15 Placement of Alloderm or dermal graft in subcutaneous tunnel.

The goal of reconstruction is to restore the nail bed and allow for more normal growth after loss due to trauma or excision. Both appearance and function should be addressed in any reconstructive effort. Reconstruction of the sterile matrix can be accomplished with a split nail bed graft from an adjacent nail bed, an adjacent digit, or a toe. Reconstruction of the germinal and sterile matrices can be accomplished with a graft from the second toe, if the donor site is large enough. Adequate soft tissue and bony support is necessary for an optimal result.

Pearls ●

Optimal appearance of the nail is most likely to occur with prompt treatment of the nail bed injury in the acute period.

●

Use of a finger tourniquet, loupe magnification, and 7/0 chromic suture is recommended to achieve the most accurate repair.

●

A Kleinert–Kutz elevator or a small periosteal elevator is useful in separating the nail plate from the adherent nail bed matrix.

●

Fractures of the distal phalanx are common with nail bed injuries and should be treated if present.

●

After trauma to the nail bed and subsequent repair, it may take up to a year for the nail to achieve its final appearance.

●

As the nail grows distally, a heaped-up appearance is present for 2–6 months before it flattens.

●

Adequate soft tissue and bony support at the fingertip are necessary for optimal nail reconstruction.

FIGURE 2.16 Postoperative appearance after pincer nail repair.


REFERENCES 1. Brown RE, Zook EG, Russell RC. Reconstruction of fingertips with combination of local flaps and nail bed grafts. J Hand Surg 1999; 24A: 345–351. 2. Kumar VP, Satku K. Treatment and prevention of ‘hook nail’ deformity with anatomic correlation. J Hand Surg 1993; 18A: 617–620. 3. Brown RE, Zook EG, Williams J. Correction of pincer-nail deformities using dermal grafting. Plast Reconstruct Surg 2000; 105: 1658. 3. Guy RJ. The etiologies and mechanisms of nail bed injury. Hand Clin 1990; 6: 9–21. 4. Shepard GH. Perionychial grafts in trauma and reconstruction. Hand Clin 2002; 18: 595–614. 5. Shepard GH. Nail grafts for reconstruction. Hand Clin 1990; 6: 79–102. 5a. Shepard GH. Treatment of nail bed avulsions with split thickness nail bed grafts. J Hand Surg 1983; 8: 49–54.

6. Van Beek AL, Kassan MA, Adson MH, Dale V. Management of acute fingernail injuries. Hand Clin 1990; 6: 23–35. 7. Zook EG. The perionychium: Anatomy, physiology and care of injuries. Clin Plast Surg 1981; 8: 21–31. 8. Zook EG, Van Beek AL, Russell RC, Beatty ME. Anatomy and physiology of the perionychium: A review of the literature and anatomic study. J Hand Surg 1980; 5: 528–536. 9. Zook EG. Reconstruction of a functional and aesthetic nail. Hand Clin 2002; 18: 577–594. 10. Zook EG, Brown RE. The perionychium. In: Green DP, ed. Operative hand surgery. New York: Churchill Livingstone, 1999; 1353–1380. 11. Lillie S, Brown RE, Zook EG, Russell RC. Free non-vascularized composite nail grafts: An institutional experience. Plast Reconstruct Surg 2000; 105: 2412–2415. 12. Brown RE. Acute nail bed injuries. Hand Clin 2002; 18: 561–575. 13. Zook EG, Guy RJ, Russell RC. A study of nail bed injuries: Causes, treatment and prognosis. J Hand Surg 1984; 9A: 247–252.

CHAPTER

Surgical Techniques for Flexor Tendon Repair

3

Kevin C. Chung

INTRODUCTION Flexor tendon injury is devastating because the loss of flexion of a digit renders that digit functionless. Unlike the extensor system, where there are interconnections between various tendon structures that may prevent retraction of the lacerated proximal tendon, the flexor tendon system is under substantial tension. Laceration of a flexor tendon needs to be repaired because the proximal tendon will often retract, which will require its retrieval and suture repair. The physiology and healing of the flexor tendon are the most common research topics in hand surgery. Research on flexor tendon healing is one of the major advancements in the field because the findings can be translated to other regions of the body that require ligament and tendon repair. At one time the flexor tendon was thought to have no intrinsic healing ability, and researchers have hypothesized that the only way flexor tendons can heal is extrinsically, whereby nutrients and blood flow from outside the tendons and work to heal the repaired tendon. However, flexor tendons do have an intrinsic healing ability. Classic research studies have shown that repaired tendons immersed in nutrient fluid have the ability to heal intrinsically by bridging of tenocytes between the lacerated tendon ends.1 This finding is important because intrinsic healing will not have the adhesions from the surrounding environment to limit excursion of the healed tendons. Ongoing research projects aim to enhance intrinsic healing while limiting healing from extrinsic sources. It has also been shown that stressing the tendon repair site will enhance intrinsic healing, which lays the foundation for early mobilization exercises after tendon repair. However, the amount of stress placed on the healed tendon needs to be carefully coordinated to prevent excess loading, which can rupture the repair. Outcomes of flexor tendon repair may improve if surgeons can improve the rate of healing through constant infusion of growth factors to the repaired tendon ends, or by stronger

repair techniques to permit an active rehabilitation protocol. An active protocol provides much better excursion of the repaired tendons, which theoretically will promote intrinsic healing and limit the adhesions associated with extrinsic healing. The current passive protocol has rather modest excursion of the repaired tendons, and adhesions limiting tendon mobility continue to be problematic.

ANATOMY OF THE FINGER FLEXOR TENDON SYSTEM The flexor tendon system is complicated and was divided into five zones by Verdan (Fig. 3.1).2 Zone 1 is at the insertion of the flexor digitorum profundus (FDP) tendon to the distal phalanx. Zone 2 consists of the region of the middle phalanx to the A1 pulley, where both the FDP and flexor digitorum superficialis (FDS) tendons are intimately contained within a tight fibro-osseous tunnel (Fig. 3.2). This is a commonly injured area that was named the ‘no man’s zone’ because laceration of tendons in this zone is associated with adhesions and loss of tendon excursion. Because of the difficulty associated with repairing and attaining functional movement in this zone, early pioneers of hand surgery, including Bunnell3 and Boyes,4,5 did not advocate repair of tendons in zone 2, but rather excision and grafting of the profundus tendon only. It was only in the 1970s that Kleinert6 showed that primary repair of zone 2 flexor tendon injury is feasible, and that patients who underwent judicious early postoperative therapy could attain acceptable function. Zone 3 is the region between the proximal A1 pulley and the carpal tunnel. This zone corresponds to the palmar region and there is no sheath encasing the flexor tendons. Therefore, injuries to this region generally have a much better outcome. Zone 4 is the region of the carpal tunnel. This region is not commonly injured because the transverse carpal liga-

29

30 Hand and Upper Extremity Reconstruction However, poor outcomes are often associated with concomitant nerve injuries involving the ulnar or median nerves. Injury to these two nerves has a rather dismal outcome, marked by incomplete sensory and motor recovery and neuropathic pain.

THUMB FLEXOR TENDON SYSTEM ANATOMY The thumb is divided into four zones (see Fig. 3.1). The anatomy of the thumb flexor tendon is different from that of the fingers because it is powered by a single extrinsic flexor tendon, the flexor pollicis longus (FPL). The tendon sheath – comprising the A1, the obliques, and the A2 pulleys – contains only one tendon, and therefore tendon excursion after repair is generally quite favorable, without the adhesions commonly seen in zone 2. Inadequate excursion of the repaired FPL may not be as troublesome as in the fingers because the thumb functions primarily as a post to face the other fingers, and full motion is generally not necessary. For the fingers, the most important pulleys are A2 and A4 (see Fig. 3.2); for the thumb, the A1 and oblique pulleys are the most important (Fig. 3.4), but one should try to preserve all the pulleys during repair if possible.

ZONE 1 FLEXOR TENDON INJURY

FIGURE 3.1 The five zones of the flexor tendon system.

ment is attached to the trapezium and hamate. Laceration in the carpal tunnel region will be blocked by these two carpal bones, and the tendons dorsal to the transverse carpal ligament typically will not be injured unless the wound is longitudinally along the direction of the tendons. Zone 5 is the region proximal to the transverse carpal tunnel and is a common region for tendon laceration. The tendon injury may be self-inflicted in suicide attempts, or may be caused by trauma. There is no bony protection in this region because the radius and ulna are dorsal to all the vital structures. Lacerations to zone 5 will often have concomitant injuries to the median and/or ulnar nerves, and perhaps the radial and ulnar arteries (Fig. 3.3). Flexor tendon injuries at the wrist are often categorized as ‘spaghetti wrist’ because the multiple lacerations may mimic the appearance of cut spaghetti. Outcomes of flexor tendon injuries in zone 5 are often quite favorable because each tendon is shielded from the others by synovial tissue.

Zone 1 consists of the insertion of the FDP onto the distal phalanx. Lacerations to zone 1 are quite uncommon. Most tendon injuries to this region involve an avulsion component in which the distal interphalangeal (DIP) joint is forcibly extended under great flexor tendon force. The typical scenario is a ‘jersey finger,’ when the middle or ring fingers grab onto the jersey of an opponent who pulls away during a football game. The sudden, forcible DIP extension against resistance causes rupture of the profundus tendon. The tendon may be avulsed with a fragment of bone, which can be seen on X-ray to determine the proximal location of the avulsed tendon. Typically, the bone will be lodged at the A3 pulley level at the decussation of the superficialis tendon. However, when the tendon is avulsed without an accompanying fracture fragment, it may retract proximally to the level of the A1 pulley, depending on whether the vincula supplying the FDP is avulsed as well. The vincula provides blood supply to the tendon system and consists of a vincula longus and a vincula brevis (Fig. 3.5). Occasionally, the vincula may hold the profundus tendon more distally. Leddy7 divided profundus tendon avulsion injury into three categories: type 1 is when the tendon retracts to the palm, type 2 is when it retracts to the proximal interphalangeal (PIP) joint, and type 3 is when it retracts to the level of the distal A4 pulley.

Indications for treating zone 1 avulsion injury Typically after about 3 weeks of no treatment, the FDP may be quite edematous and cannot be guided through the pulley system to be attached into the distal phalangeal bone. In selected cases the tendon is lodged at the level of the A2 pulley, and the tendon can still be passed through

Surgical Techniques for Flexor Tendon Repair 31 A1 A5

C3

A4

C2

A3

C1

A5

C3

A4

C2

A3

C1

A2

A1 A2

FIGURE 3.2 Anatomy of the zone 2 flexor tendon system.

FIGURE 3.3 Cross-sectional anatomy of zone 5.

Palmaris longus tendon Median nerve Flexor carpi radialis tendon

Palmar carpal ligament

Flexor digitorum superficialis tendons Ulnar artery

Flexor pollicis longus tendon

Ulnar nerve

Radial artery Flexor carpi ulnaris tendon

Pronator quadratus muscle

Radius

Flexor digitorum profundus tendons

the tendon system and be attached to the distal phalanx. Therefore, the 3-week period is not the absolute criterion for not performing primary repair. To determine the proximal extent of the avulsed FDP tendon, radiography (if associated with a fracture) or ultrasound may be helpful. Myostatic contraction associated with a retracted tendon may also prevent the tendon from being able to be inserted into the distal phalanx without undue tension.

Ulna

Contraindications for treating zone 1 avulsion injury Profundus tendon laceration or avulsion injury occurs more than 3 weeks after injury, and if the proximal retraction of the tendon is at the level of the A1 pulley. If the avulsion injury is not detected for several months, then primary repair of the tendon is not possible. One

32 Hand and Upper Extremity Reconstruction should resist the temptation to place a tendon graft within an intact FDS tendon. The functional limitation of an immobile DIP joint is not great and patients can generally tolerate this. If there is volar laxity of the DIP joint, then the joint can be fused or volar capsule advancement can be performed to maintain DIP stability. Placing a tendon graft through an intact FDS tendon may cause tendon adhesions, and the prolonged rehabilitation may cause an even greater functional problem.

Operative approach The ring finger is often involved in FDP avulsion injury (Fig. 3.6). It may be difficult to make a full fist because of

A2

Oblique

A1

FIGURE 3.4 Pulley system of the thumb.

the quadriga effect, in which a checked ruptured FDP tendon prevents the other FDP tendons from full excursion because of a shared common muscle belly (Fig. 3.7). Preoperatively, an X-ray is necessary to evaluate whether the bone is avulsed, which can help determine the proximal extent of the avulsed tendon (Fig. 3.8). If the X-ray does not show bone fragments, ultrasound can be helpful to determine the proximal location of the avulsed tendon, but is not necessary because exploration of the tendon system will determine this. A zigzag incision is made to explore the tendon system (Fig. 3.9). In this case, there is bone attached to the ruptured profundus tendon, which is held by the pickup. The Keith needle skewers the profundus tendon proximally to prevent its retraction (Fig. 3.10A,B). When the profundus tendon is retracted more proximally, a transverse A3 pulley incision is made to identify the tendon. On rare occasions the A1 pulley will need to be opened with an incision in the palm, and a small red Robinson catheter can be threaded distal to proximal through the tendon sheath to retrieve the proximal tendon. Once the tendon is sewn to the end of the catheter, the catheter can be gently pulled through the sheath (Fig. 3.11). It is quite important to place the catheter gently through the FDS decussation so that the FDP tendon can go through its original path. If the tendon is rerouted through a new path, adhesions may form, which can cause problems with excursion. The flexor tendon is then pulled through the A5 pulley. By flexing the finger, one can lessen the tension on the tendon and allow it to advance to the distal phalanx. Even though the bone is avulsed, the fragment is usually too small to accommodate bone fixation using a screw. Occasionally the bone component can be large enough that a single screw fixed to the distal phalanx is sufficient to stabilize the avulsed tendon. In most cases the tendon will need to be advanced and secured within the bone of the distal phalanx using a Bunnell criss-cross suture with 2/0 Prolene. Prolene sutures are used because they can slide and can be pulled off the bone after healing. It would be a mistake to use a braided suture because braided sutures do not slide and will be partially retained under the nail bed after attempted removal, which may lead to infection. The cortex of the distal phalanx is partially removed using a curette (Fig. 3.12). Two Keith needles are placed through the mid-portion of the dorsal nail (Fig. 3.13). It is important

FIGURE 3.5 Vincula system that provides blood to the tendons.

VLS

VBS

VLP

VBP

Surgical Techniques for Flexor Tendon Repair 33

FIGURE 3.6 Functional picture showing the inability to flex the right ring finger due to a profundus tendon rupture.

FIGURE 3.7 Functional picture showing the difficulty of flexing the other fingers because of the quadriga effect from the checked FDP tendon to the ring finger.

not to puncture the germinal matrix at the nail fold to avoid causing nail deformity. The two ends of the Prolene suture are inserted into the Keith needles and pulled through the nail. The Keith needles are used again to pass the Prolene sutures through folded Xeroform gauze and are tied over a button (Fig. 3.14). One should watch the entry of the profundus tendon into the bone when tying the suture so that the tendon will contact the distal phalanx to achieve better healing. The wrist and fingers are flexed to take the tension off the tendon, and the sutures are tied down using at least 10–15 ties to avoid loosening. Once the suture is secured, the finger posture should show the natural flexion cascade of the DIP joint (Fig. 3.15). The bone fragment (Fig. 3.16,

FIGURE 3.8 Lacerated profundus tendon with the arrow pointing to the attached bone chip.


Red Robinson catheter Distal phalanx Proximal phalanx

Middle phalanx

Retracted profundus tendon sutured to catheter A5 A4

A3

A2

FIGURE 3.9 A zigzag incision is used to expose the flexor tendon system.

A

A1 (opened)

FIGURE 3.11 Diagram showing a catheter threaded through the pulley system and sewn to the avulsed tendon for retrieval.

arrow) has healed to the distal phalanx. The wound is closed using 5/0 nylon sutures and the patient is placed in a dorsal blocking splint with the wrist flexed at about 60º and the MCP joints at about 90º. Gentle passive motion of the DIP joint will be initiated 1 week after surgery. The button is left in place for 8 weeks, and the Prolene suture will be pulled through the tendon and bone at that time. Strengthening exercises are not started until 8 weeks after surgery.

Optimizing outcomes ● ●

B FIGURE 3.10 A The pick-up is holding the bony attachment to the profundus tendon. B The Keith needle is used to prevent retraction of the avulsed tendon.

●

●

Early recognition of the injury and repair Atraumatic handling of the avulsed tendon in order to guide it through the pulley system Strong attachment of the tendon into a bone tunnel in the distal phalanx Judicious passive therapy to prevent joint contracture and enhance tendon excursion


Complications The most common complication from this injury is inadequate tendon excursion and finger stiffness. Many of these injuries are not recognized immediately. The avulsed tendons may become edematous and be difficult to pull through the pulley system. The tight interface between the pulley system and the edematous tendon may cause postoperative adhesions, resulting in incomplete finger flexion. A less common complication is tendon rupture. If this is the case, it may be difficult to retrieve the tendon and repair it again. However, one should explore the tendon and evaluate whether reattaching it can still be useful. It is

Curette

Distal phalanx Profundus tendon

A5

Middle phalanx A4 A3

A2

generally not a good idea to place a tendon graft through the intact FDS tendon system because of the technical difficulty and potential problems with adhesions, which may severely affect finger movement (Fig. 3.17A,B). When tendon repair is not possible because of delay, DIP fusion is an effective operation that will position the finger in a good functional posture of about 10–15º of flexion without the need for a complicated tendon grafting procedure.

ZONE 2 FLEXOR TENDON INJURY Zone 2 flexor tendon injuries are often accompanied by digital nerve or artery lacerations. Typically, the surgeon has about 4 weeks to repair a lacerated zone 2 flexor tendon. After this time the tendon may have retracted and shortened, which makes repair much more difficult and outcomes less favorable; for delayed presentation when primary repair is not suitable, one should consider excising the FDS and FDP and reconstruct using a tendon graft. Depending on the tendon graft available, there are two options for the procedure. One is to repair the proximal tendon in zone 3, another to repair the tendon in zone 5. Typically, the palmaris longus tendon can reach the palm easily, and in some cases is long enough to reach the distal end of the wrist crease. If the patient has a plantaris tendon, this is long enough to bridge between the distal phalanx and the proximal wrist. Proximal repair at the wrist is favorable because there is sufficient space between tendons, which minimizes adhesions at the wrist.

Operative approach

A1 (opened)

FIGURE 3.12 Diagram showing a curette removing the distal portion of the distal phalanx.

Physical examination will demonstrate the extended finger posture typical of lacerated zone 2 flexor tendons (Fig. 3.18). The patient may complain of sensory loss if the digital nerves are injured. Occasionally the fingers may be ischemic, and one must prepare for digital artery reconstruction. The exposure incision needs to be creative to incorporate the laceration into the flap design (Fig. 3.19). If the laceration is transverse, the exposure can be extended into a mid-axial incision and a zigzag incision both distally and proximally. A zigzag incision at the laceration site will make the tip of the flap very narrow; this may lead to flap

Profundus tendon with Prolene sutures A4

A5

Two Keith needles A3 A2 A1

FIGURE 3.13 Two Keith needles are placed through the nail and used to pull the sutures through the bone to secure the tendon to the distal phalanx.

36 Hand and Upper Extremity Reconstruction Button

Xeroform gauze pad

Flexor tendon

FIGURE 3.14 The sutures are then tied over a button to secure the end of the profundus tendon to the distal phalanx.

necrosis, which can be problematic because the underlying flexor tendon and nerve repairs will be exposed. The flaps are tagged and retracted using 4/0 nylon sutures and sharp dissection is carried out using a no. 15 blade to expose all the vital structures relatively atraumatically. Digital nerves and vessels are identified and a portion of the A2 pulley is opened to expose the lacerated flexor tendons. The superficialis tendons are repaired first because they lie more dorsally, and each slip of the FDS tendon can be repaired using horizontal mattress 4/0 braided sutures (Fig. 3.20). The superficialis tendons are flat at the level of zone 2, and a core stitch repair is usually not possible. The proximal profundus tendon should be brought through the decussation of the superficialis tendon and secured using a

FIGURE 3.15 Flexion cascade of the DIP joints after surgery. FIGURE 3.16 X-ray showing the healed bony fragment that was pulled off when the tendon became avulsed.

A

B

FIGURE 3.17 A Severe PIP contracture after failed tendon grafting through an intact FDS tendon. B Improved finger posture after tendon graft excision and PIP fusion.


Back of circumferential sutures

A

Outer core locking suture

FIGURE 3.18 Finger posture typical of lacerated zone 2 flexor tendons.

B

Horizontal mattress inner core suture

C

Complete circumferential suture

FIGURE 3.19 Flap design and incision that incorporates the laceration.

D FIGURE 3.21 Sequence of four-stranded suture repair for the lacerated tendon.

FIGURE 3.20 Repaired zone 2 lacerated tendons using horizontal mattress 4/0 braided sutures.

Keith needle to prevent its proximal migration. The profundus tendon has a round configuration, and a four-strand suture repair augmented by an epitendinous 6/0 Prolene locking repair is preferable. The sequence of repair is to place a 6/0 Prolene epitendinous circumferential suture onto the dorsal half of the profundus tendon (Fig. 3.21A). This outer locking suture will complete the volar epitendinous repair after tying the core sutures (Fig. 3.21B). Next, a grasping locking core suture is placed, followed by a central core horizontal mattress 4/0 Ethibond suture to bring the tendon ends together (Fig. 3.21C). The suture

38 Hand and Upper Extremity Reconstruction knot can either be within the tendon or outside it, which avoids having too much suture material within the tendon substance that can hinder healing. The final step is to close the anterior tendon gap using a locking 6/0 Prolene suture tied to itself (Fig. 3.21D). This suture not only adds strength to the repair, but also tidies up the rough edges of the tendon to make it a smooth, gliding surface (Fig. 3.22). Once the tendon is repaired, there is less tension on the nerves and vessels. The nerves can be repaired using 9/0 nylon epineurial stitches under microscopic guidance. Vein grafts are harvested from the volar wrist to repair the digital arteries of the ring and little fingers (Fig. 3.23). The wound is closed (Fig. 3.24) and the fingers now have a normal cascade. A dorsal blocking splint is placed with the wrist flexed at about 60º and the MCP joints at about 90º to take the tension off the tendon repair. When the tendon repair is not accompanied by nerve or vessel repairs, the patient can start

passive mobilization exercises 2 or 3 days after the operation. However, when there are digital nerve or vessel repairs, the author delays therapy for about a week to allow the edema to settle and to prevent avulsion of the nerve or the arterial repairs.

Therapy It is quite important that the therapist treating the patient is aware of the strength and type of repair used as well as the number of structures repaired. Typically, patients are started on passive mobilization exercises with passive finger flexion and active extension with rubber band traction for 3.5 weeks. After this period the wrist is extended to the neutral position and the patient is gently started on active exercises for another 4 weeks. Eight weeks after surgery the patient begins strengthening exercises (Fig. 3.25A,B).

Complications

FIGURE 3.22 This picture shows how the use of 6/0 Prolene sutures can clean up the tendon ends, allowing for smoother gliding.

The most disastrous complication after flexor tendon repair is tendon rupture. If this occurs the patient will need to return immediately to the operating room for repeat repair. Otherwise, reconstruction with a tendon graft will be necessary. In most situations the repair can be salvaged by an immediate return to the operating room. Tendon rupture complications typically occur about 1 week after surgery, when the patient begins therapy, and after the 3.5-week period when they begin active exercises. The nadir of tendon repair strength is typically between weeks 1 and 2, after which time the repair starts to gain more strength as the tendon heals (Fig. 3.26). Many have demonstrated that an increased number of sutures crossing the tendon repair site will add more strength to the repair. The six-strand repair will allow the patient to start active exercises, but the bulkiness of the tendon at the repair site may hinder excursion. The increased strength at the tendon repair to allow an active therapy protocol is an ambitious and promising direction for the future.

FIGURE 3.23 Repaired digital arteries and nerves.

FIGURE 3.24 Closure of wound, showing the natural cascade of the fingers.


A

B

FIGURE 3.25 Postoperative functional pictures showing the ability to flex and extend the fingers.

FIGURE 3.26 Flexor tendon repair: strength versus force. Two-, fourand six-strand repairs plotted against passive light active flexion and strong grip, adjusted for friction, edema and stress.

and vessel injuries in a scarred field, and the technical difficulty of the operation. Therefore, the author does not advocate tenolysis if the patient has attained outcomes in the good range. However, if the results are in the poor range, tenolysis is worthwhile. I will perform tenolysis at 6 months after the initial repair, by which time the tendon has healed sufficiently to withstand the trauma of the procedure. Tenolysis is one the more complicated procedures in hand surgery because the scar can be quite unyielding, and it is difficult to separate the tendons from the tightly adherent pulley system. The patient should understand the risks of the procedure, which can be an occasional tendon rupture due to devascularization and weakening of the tendon repair site. The therapist must also be involved in the decision regarding tenolysis. If the patient is continuing to improve in therapy, the tenolysis should be delayed until they have reached maximum improvement. Equally importantly, the condition of the tendon during tenolysis must be conveyed to the therapist, so that they can design a program based on the surgeon’s impression of the strength of the healed tendons.

Outcomes

TWO-STAGE TENDON RECONSTRUCTION

8000

Force in grams

6000 Strong grip 6-Strand

4000

4-Strand 2000 2-Strand Light grip 0

Passive Repair

1 3 Time in weeks

6

Tendon outcomes are based on measurement of the flexion arc at the MCP, PIP, and DIP joints minus the extension lag. The MCP joint range of motion is 0–110º, that of the PIP joint is 0–90º, and of the DIP is 0–90º. Therefore, a normal total active motion (TAM) will give the finger a maximum of 280º. However, it is quite unlikely that this goal will be achieved after flexor tendon repair. A poor result is when the total active motion is less than 150º, a fair result is between 150º and 180º, a good result is between 180º and 220º, and an excellent result is over 220º. If the patient is able to achieve results in the good range, it will be difficult to advise them to undergo tenolysis to achieve outcomes in the excellent range. There are inherent complications with tenolysis, such as tendon rupture, more scarring to reduce tendon excursion, pulley injury, nerve

Stage 1 For a patient who presents with an unrepaired tendon, a tendon rupture, or a severely scarred flexor tendon system after repair, it may not be possible to perform a single-stage graft because the tendon sheath can be quite scarred and the newly placed graft will be bound down in scar tissue rather quickly. In addition, the scarred tendon system will limit joint motion to cause chronic joint contracture, which needs to be released to achieve good passive motion prior to insertion of a graft (Fig. 3.27A,B). In these situations a two-stage repair strategy is more appropriate. In the first stage, the scarred tendon is excised entirely while preserving the crucial A2 and A4 pulleys, but all viable pulley systems should be preserved. A stump of the profundus


A FIGURE 3.28 Stage 1 flexor tendon repair using a silicone rod threaded through the pulley system.

B FIGURE 3.27 A, B Chronic joint contracture due to unrepaired flexor tendon laceration.

tendon is preserved to suture to the silicone rod distally. The silicone rod is made up of a silicone outer core and a central fabric material that can hold sutures. The joint capsule must be released to achieve good passive motion of the fingers. The silicone rod is then threaded through the pulley system and the distal end sewn to the distal profundus tendon using a horizontal mattress 4/0 Ethibond suture (Fig. 3.28). Proximally, the silicone rod is placed next to a potential donor tendon in preparation for the second-stage reconstruction. If the palm is severely scarred and no donor tendon in the vicinity is suitable for reconstruction, the silicone rod can be passed into the wrist in preparation for using an expendable tendon at the wrist, such as the proximal FDS or FDP tendon from the injured finger, to power the graft (Fig. 3.29). At the first-stage reconstruction the surgeon may find associated nerve injuries that need to be repaired with either nerve graft or nerve tube. The anatomy of repair in this region must be drawn out in preparation for the second-stage procedure, so that the surgeon can avoid injuring these critical structures that may be embedded in scar tissue. Over the next 3 months

FIGURE 3.29 Stage 1 flexor tendon repair showing no palmar donor tendon available. Therefore, the rod is inserted into the wrist so the proximal FDS or FDP tendons can be used.

the patient will engage in passive exercises to the finger joints in order to prepare for the second stage of reconstruction.

Stage 2 Once the patient has achieved supple joint motion, the second-stage reconstruction is planned. If the proximal silicone rod is at the palm, then the palmaris longus has sufficient length for tendon grafting. A V-shaped incision is made at the level of the DIP joint to expose the distal silicone rod and a proximal palmar incision is made to expose the proximal rod (Fig. 3.30). If the location of the rod cannot be ascertained preoperatively, intraoperative fluoroscopy can identify it. Occasionally, the rod may have been dislodged distally. In this situation it is tricky to retrieve the rod and place it into the tendon sheath, but this problem


FIGURE 3.30 Incisions for the stage 2 repair. A V-shaped incision is made at the level of the DIP joint to expose the distal silicone rod and a proximal palmar incision is made to expose the proximal rod.

FIGURE 3.32 A curette is used to remove the cortical window over the volar distal phalanx to allow for tendon insertion into the bone.

FIGURE 3.31 Once the rod is removed from the distal end of the tendon, a mosquito is used to prevent the rod from migrating into the palm.

FIGURE 3.33 Identification of the proximal donor tendon by retrieving the suture tag on the donor tendon that was placed in the stage 1 repair.

is not common because there is no tension placed on the rod during finger motion. The silicone rod is found distally and detached. A mosquito clamp is used to secure the distal end of the rod to prevent its migration (Fig. 3.31). It is crucial to have proximal and distal control of the silicone rod so that it cannot be accidentally dislodged from the tendon sheath. However, if the rod is dislodged within the tendon sheath during exposure, it can be inserted through the established tendon sheath. The distal profundus tendon is partially elevated from the bone. A curette is used to remove a cortical window over the volar distal phalanx so that the tendon can be inserted into the bone using a pull-out button (Fig. 3.32). The proximal donor tendon is found by retrieving the suture tag on the tendon for ease of identification (Fig. 3.33). The palmaris longus tendon graft (Fig. 3.34) is then sutured to

the proximal silicone rod and gently guided into the tendon sheath. The distal tendon is woven using a 2/0 Prolene suture in a Bunnell stitch, and the graft is secured to the distal phalanx as described earlier. The slightly redundant distal profundus tendon is sutured to the tendon graft using 4/0 Ethibond suture for additional support. Excursion of the tendon graft is evaluated by pulling the graft to assure that the distal insertion is strong enough to withstand motion and to check whether the finger has good passive movement (Fig. 3.35A,B). The proximal tendon graft is woven to the donor profundus tendon, which has excellent excursion (Fig. 3.36A,B). The tension is set sufficiently so that the finger has slightly more flexion than the normal cascade (Fig. 3.37A–C). A dorsal blocking splint is placed, and the patient is started on gentle passive mobilization exercises for the next 4 weeks, followed by 4 weeks of active exercises.


A FIGURE 3.34 Palmaris longus tendon graft.

B FIGURE 3.36 Pulvertaft weave of the tendon graft to donor tendon.

The button is removed 8 weeks after surgery and strengthening exercises are begun. A

Outcomes The results of two-stage tendon reconstruction may not be ideal given the length of recovery and the amount of scars within the tendon sheath. However, patients usually have satisfactory improved function with this approach, and will retain a useful finger that can participate in most activities.


B FIGURE 3.35 A, B Checking the tendon excursion to ensure the graft is strong enough.

●

Ensure that the pulley system is preserved. If a critical pulley is absent, one can recreate a pulley by using a cuff of the extensor retinaculum sutured to the pulley remnant, or by using the discarded profundus or superficialis tendon from the excised tendon system. The tendon is looped around the bone to recreate a pulley system overlying the silicone rod. The distal tendon–bone repair must be secure to achieve healing. The proximal donor tendon must have at least 3 cm of excursion in order to provide adequate movement of the tendon graft.


Proper palmar digital nerves of thumb A1 of thumb

A

Flexor pollicis longus tendon

FIGURE 3.38 Anatomy of the thumb showing the intimate relationship between the digital nerves and the proximal A1 pulley.

FLEXOR POLLICIS LONGUS TENDON B

C

FPL lacerations will often be accompanied by digital nerve injuries. Both the radial and ulnar digital nerves have an intimate relationship with the proximal A1 pulley of the thumb (Fig. 3.38). The proximal FPL tendon retracts by muscular contraction after laceration, and the tendon is often found at the wrist level. One may flex the wrist and milk the FPL tendon into the sheath, and occasionally the proximal tendon can be retrieved by passing a tendon retriever down the sheath to grasp the tendon. In most cases a separate incision is needed at the wrist over the radial border of the FCR tendon, and the FPL can be found dorsal to the FCR tendon. A Robinson catheter can be passed down the tendon sheath from distal to proximal, and the FPL tendon is sutured to the catheter and retrieved to the laceration site by flexing the wrist to take the tension off the tendon. A Keith needle is used to secure the FLP tendon to the A1 pulley to prevent proximal retraction. The tendon is repaired using a standard four-strand repair augmented with an epitendinous 6/0 Prolene locking suture. The therapy protocol is similar to that for zone 2 flexor tendon injuries.

FIGURE 3.37 A, B, C Cascade of the fingers showing slightly more flexion than normal.

ZONE 3 FLEXOR TENDON INJURY Injury in this zone is quite easy to repair. The tendon ends are quite close to each other and a proximally retracted lacerated tendon is not too difficult to retrieve. However, given hematomas and edema are associated with traumatic


Injury in zone 5 is quite common. The wrist and forearm are not protected by bony structures and lacerations can cause multiple structural injuries to nerves, vessels, and tendons (Fig. 3.39). Understanding the topography of the structures in the cross-sectional arrangement is important to effectively identify injured structures (see Fig. 3.3). The flexor tendons in the wrist are arranged in three layers. The most superficial layer are the wrist flexors, which consist of the FCU, the PL, and the FCR. Immediately dorsal and radial to the PL is the median nerve. If the patient has a

finger flexor tendon laceration in zone 5, it is highly likely that the median nerve will be lacerated because of its location superficial to the finger flexors. The second layer consists of the superficialis tendons, which are arranged with the middle and ring fingers more superficial to the index and little finger tendons. The third layer consists of the profundus tendon with the index, middle, ring, and little fingers; the FPL tendon lies radially between the second and third layers. The index FDP tendon usually has an independent muscle belly, but the middle, ring, and little fingers share a common muscle belly. Exposure of the structures in the wrist is not too difficult. The laceration can be extended by incisions proximally and distally. The forearm fascia is sharply incised with no. 15 blades, and blade dissection is used to rapidly dissect the individual structures by separating the synovial tissues from each tendon. When the laceration occurs with the wrist flexed, the distal tendons may be found in the carpal tunnel. Therefore, a carpal tunnel incision is made to expose the distal contents. When one understands the cross-sectional relationship of the tendon structures, one should be able to match respective tendons for repair, starting from level 3 and proceeding to the superficial structures. It is critical that the tendons are appropriately sutured to their counterparts, because it is quite disturbing at the end of the case when there is an extra tendon in the wound without an accompanying proximal or distal tendon. The author typically uses two horizontal mattress sutures to repair the tendons (Fig. 3.40). There is so much space within the wrist that tendon adhesions are usually not problematic. If both the radial and ulnar arteries are injured, they are repaired first to establish blood flow. I will repair a lacerated artery at the wrist because technically it is not difficult and it ensures good blood supply to the hand. The median nerve is repaired last. When a median nerve injury is suspected, one should not wait for a few days to repair the nerve (Fig. 3.41). Retraction of the nerve several days after injury makes it extremely difficult to bring the nerves together

FIGURE 3.39 Lacerated zone 5 showing multiple lacerations to tendons, nerves, and vessels.

FIGURE 3.40 Repaired median nerve and tendons.

injury, it may be difficult to find the proximal lacerated tendons. A good landmark is to identify the lumbrical muscles, which are attached to the radial borders of the FDP tendons. Pulling on the lumbrical muscles will always retrieve the profundus tendons. By placing traction on the profundus tendons, the FDS will be visible as well because of the shared synovial layer between the two tendon systems. In this zone the FDS tendon has much more substance and the typical four-strand repair can be performed. It is not necessary to perform an epitendinous Prolene suture repair because the two tendon systems are not within a restrictive tendon sheath, and tendon gliding between the systems is usually not too prohibitive.

ZONE 4 Tendon lacerations in this zone are quite unusual unless the laceration is longitudinal in orientation. A transverse laceration in the carpal tunnel region will often be blocked by the trapezium and the hamate. However, one should understand the topography of the flexor tendons and the median nerve in the carpal tunnel, and systematic repair of the tendons can be achieved by matching the shape of the laceration proximally and distally, as well as the size of the tendons.

ZONE 5


FIGURE 3.41 Median nerve laceration.

without flexing the wrist excessively. If the nerve can be repaired within 24 hours it is technically quite easy to bring the nerves together tension free. The nerve is examined under the microscope and the ends are cut using a fresh no. 11 blade distally and proximally to achieve healthy nerve ends for repair. Vascular landmarks on the proximal and distal nerves will allow appropriate alignment of the epineurium using 8/0 or 7/0 nylon sutures (see Fig. 3.40). There are staining methods to identify motor and sensory fascicles, but these techniques are still quite difficult to perform. Fascicular suturing of the median nerve without ensuring proper matching can create a mismatch of fascicles that will be deleterious to nerve regeneration. For the median nerve at the wrist, I prefer epineural repair and engage the nerve specificity properties for appropriate matching of fascicles. The ulnar nerve at the wrist has two predictable sensory and one predictable motor fascicle; I will perform fascicular repair for the ulnar nerve at the wrist. It is important to match the motor fascicle and the sensory fascicles using interfascicular repair to ensure good recovery of important intrinsic muscle function (Fig. 3.42).

Therapy The wrist is splinted with a dorsal blocking splint in approximately 60º of flexion. The patient can start gentle passive motion exercises within a few days of surgery. Outcomes of flexor tendon repair at the wrist are predictably good if the patient is compliant with therapy and the therapist understands the therapy protocol for this region. Similar to zone 2 flexor tendon injuries, patients are progressed through a sequence of passive motion exercises, active motion exercises, and strengthening exercises at the end of the eighth week after surgery. Nerve recovery for median and ulnar nerve laceration at the wrist is always incomplete. This is complicated by neuropathic pain, which is difficult to treat and will be most bothersome to the patient.

Sensory fascicles Motor fascicles Blood vessel

FIGURE 3.42 Ulnar nerve anatomy showing motor and sensory fascicles.

Complications Complications of zone 5 injuries relate primarily to median nerve dysfunction due to the mismatch of sensory and motor fibers, as well as incomplete recovery of sensation and thenar muscle function. Patients typically complain of prolonged periods of neuropathic pain that is very difficult to control and can be quite devastating, particularly for manual workers. Scarring of tendons in zone 5 is quite uncommon. With judicious therapy and strengthening exercises, most of the minor adhesions can be broken up and will soften over time. Tenolysis in this region is generally not necessary.

CONCLUSION Understanding the anatomy and physiology of flexor tendon is crucial to treat and repair these injuries. Handling of

46 Hand and Upper Extremity Reconstruction tendon ends must be meticulous to prevent scarring that could hamper healing. Flexor tendon injuries and related lacerated structures should be exposed meticulously but efficiently using sharp dissection with a knife. Aggressive spreading of scissors through tissue plane induces too much trauma to the delicate tissue. The author prefers sharp dissection with a knife to separate the tissue layers. The surgeon must work closely with the therapist to ensure that the patient receives the most optimal and attentive therapy protocol in order to optimize outcomes. Despite great advances in tendon repair techniques and therapy protocols, inadequate outcomes are not uncommon. Tremendous research effort is under way to enhance the healing capability of tendons in order to achieve earlier recovery of function and stronger repairs to withstand more aggressive active protocols in an effort to decrease tendon adhesions and to return useful function.

REFERENCES 1. Abrahamsson SO, Lohmander S. Tendon healing in vivo. An experimental tendon. Scand J Plastic Surg Hand Surg 1989; 23: 199–205. 2. Verdan CE. Primary repair of flexor tendons. J Bone Joint Surg 1960; 42A: 647–657. 3. Bunnell S. Repair of tendons in the fingers. Surg Gynecol Obstet 1922; 35: 88–97. 4. Boyes JH, Stark HH. Flexor tendon grafts in the fingers and thumb. A study of factors influencing results in 1000 cases. J Hand Surg 1971; 53A: 1332–1342. 5. Boyes JH. Evaluation of results of digital flexor tendon grafts. Am J Surg 1955; 89: 1116–1119. 6. Kleinert HE, Kutz JE, Cohen MD. Primary repair of zone II flexor tendon lacerations. In: AAOS Symposium on Tendon Surgery in the Hand. St Louis: CV Mosby, 1975; 91–104. 7. Leddy JR, Packer JW. Avulsion of the profundus tendon insertion in athletes. J Hand Surg 1977; 2: 66–69.

CHAPTER

The Management of Extensor Tendon Injuries

4

Brent Bickel, David B. Shapiro, Michael W. Keith, and Harry A. Hoyen

ANATOMY The extensor apparatus is a finely tuned system that relies on the complex interplay between the intrinsic muscles (originating and inserting on the hand) and the extrinsic muscles (originating proximal to the wrist and inserting distally on the hand). Any logical repair algorithm must have as its basis a firm understanding of the anatomy of the extensor system. The tendons of the extrinsic musculature are aligned at the wrist into the six dorsal wrist compartments (Fig. 4.1). The fibro-osseous extensor retinaculum creates the confines of their respective compartments. The retinaculum acts as a pulley to prevent ‘bowstringing’ of the tendons during combined finger and wrist extension. The first dorsal compartment contains the abductor pollicis longus (APL) and extensor pollicis brevis (EPB), which insert on the bases of the thumb metacarpal and proximal phalanx, respectively. The APL has multiple tendon slips in up to 40% of cases.1 The extensor carpi radialis longus (ECRL) and brevis (ECRB) are contained within the second dorsal compartment and attach to the bases of the index and long metacarpals, respectively. The third compartment contains only the extensor pollicis longus (EPL) tendon, which courses around Lister’s tubercle obliquely and inserts onto the distal phalanx of the thumb. The EPL not only provides interphalangeal joint extension, but also adds an adduction moment to the thumb. The fourth compartment contains the extensor indicis proprius (EIP) and extensor digitorum communis (EDC) tendons that form the bulk of the extensor apparatus; they attach primarily to the base of the middle phalanx via the central slip. The EIP and extensor digiti minimi (EDM) can be differentiated from their EDC counterparts at the level of the metacarpophalangeal joint by their more ulnar position (Fig. 4.2). The EDM lies in the fifth dorsal compartment over the distal radioulnar joint and is responsible for small finger

extension independent of the EDC. The extensor carpi ulnaris (ECU) is contained in the sixth and most ulnar dorsal compartment. Its insertion on the base of the small finger metacarpal allows for wrist extension and ulnar deviation. The intrinsic muscles of the hand contribute to the extensor mechanism and include the interosseous and lumbrical muscles. These muscles (except for the two radial lumbricals, which are innervated by the median nerve) are innervated by the deep branch of the ulnar nerve. There are four dorsal bipennate and three volar unipennate interossei. The dorsal interossei abduct the fingers away from the centrally located long finger. They accomplish this by originating on adjacent borders of the metacarpals and inserting onto the radial side of the proximal phalanx when the muscles are over the radial side of the long finger, and onto the ulnar side of the proximal phalanx when the muscles are over the ulnar side of the long finger. Their combined action serves to abduct the fingers from the midline. The three unipennate palmar interossei adduct the fingers towards the midline. When located ulnar to the central long ray, they originate on the radial border of the metacarpal and insert on the radial aspect of the proximal phalanx to pull the ulnarly located finger towards the midline. This is a mirror image on the index metacarpal to pull the radially located index finger toward the long ray. All of the interossei also contribute to the extensor apparatus via their contributions to the lateral bands. Their combined pull results in flexion at the MP joint and extension at the PIP and DIP joints. The lumbricals originate on the radial border of the flexor digitorum profundus tendon just distal to or occasionally within the carpal tunnel. Their initial path is volar to the intermetacarpal ligament and their tendons work similarly to the lateral bands to provide MP joint flexion and PIP and DIP joint extension. However, the lumbrical muscle is unique because it is the only muscle that bridges

47


FIGURE 4.1 Dorsal wrist compartments; hand is at the left side of the figure. FIGURE 4.3 Juncturae tendinae interconnections (arrows).

FIGURE 4.2 EIP ulnar to EDC in zone 5. FIGURE 4.4 Radial sagittal band of the index finger.

the extensor and flexor system by providing synchronous motion during finger extension and flexion. On the dorsum on the hand, between the retinaculum proximally and the MP joint distally, the EDC tendons are connected by the juncturae tendinae (Fig. 4.3). Their interconnections can make tendon lacerations proximal to the MP joint difficult to diagnose because the distal tendon connection can maintain extension of the finger with the lacerated extensor tendon. The extensor mechanism distal to the juncturae can become more complex because of the inherent connection between the extrinsic and intrinsic systems. The EDC tendons pass over the MP joint and are held in a centrally located position by the sagittal bands (Fig. 4.4). The sagittal band fibers maintain the extensor in a central location by fibers that attach into the volar plate of the proximal phalanx. The EDC contributes to MP joint extension through these fibrous insertions. Distal to the MP joint the extensor system divides into three distinct portions (Fig. 4.5), the central slip and the two lateral bands.

FIGURE 4.5 Lateral bands (large arrows) and central slip (small arrow) at the level of the proximal phalanx.

The Management of Extensor Tendon Injuries 49 and a flexed posture of the PIP. This deformity presents as a ‘boutonnière’ deformity. If the PIP joint is not maintained in an extended position after central slip trauma, the lateral bands migrate volarly, causing a flexed PIP posture. Distally the lateral bands form a conjoined tendon that inserts onto the base of the distal phalanx to provide terminal extension of the DIP joint. The spiral oblique retinacular ligament originates on the flexor sheath volarly at the PIP joint and courses distally and dorsally to contribute to the dorsal extensor mechanism and stabilize the PIP joint.

INNERVATION SEQUENCE

FIGURE 4.6 The transverse retinacular ligament shown by the arrow at the level of the PIP laterally viewed.

FIGURE 4.7 Triangular ligament holding the lateral band in a dorsal position.

The central slip continues distally to insert onto the base of the middle phalanx. The intrinsic contribution to the lateral bands passes volar to the MP axis, thereby aiding MP flexion, whereas the terminal tendons contribute to PIP and DIP extension through their relatively dorsal location. This relationship permits smooth conjugated finger flexion and extension.2 The lateral band position is maintained at the level of the PIP joint by the transverse retinacular ligament (TRL) (Fig. 4.6). The clinical significance of the TRL after PIP and central slip trauma is in preventing dorsal subluxation of the lateral bands at the level of the PIP, which can cause a hyperextended posture and ‘swan-neck’ deformity at the PIP joint. The lateral bands join at the level of the middle portion of the middle phalanx dorsally. They are held dorsally by the triangular ligament (Fig. 4.7). Rupture or attrition of this ligament can result in volar lateral band subluxation

The origin of the forearm extensor musculature is the lateral humeral epicondyle and the interosseous membrane. Each of the muscles has a relatively flat muscle belly prior to forming a flat, broad tendon. The myotendinous junction for the wrist extensors is in the mid-forearm, whereas that of the finger extensors is in the distal forearm. Innervation comes from the radial nerve. Based on research work with functional electrical stimulation, the motor point for each nerve is located fairly consistently just proximal to the myotendinous junction. There is usually one larger motor branch from the radial nerve or posterior interosseous nerve to each muscle. The sequence of innervation is an important distinction for this muscle group. In contrast to some nerves that branch in a tree-like fashion, the radial nerve innervates the extensor musculature in an orderly pattern from proximal to distal. The main radial nerve supplies the brachioradialis, ECRL, and occasionally the ECBR. The posterior interosseous nerve innervates the ECRB, EDC, ECU, EIP, and EPL sequentially. The order of innervation is important in differentiating a radial nerve injury from a mechanical myotendinous or muscle disruption after forearm lacerations. Understanding the innervation is likewise helpful when observing clinical recovery after radial nerve injury or repair.

INJURY AND PRESENTATION The description of extensor injuries is based on eight zones for the hand and five for the thumb, as described by Verdan.3 The odd-numbered zones lie over joints, whereas the even-numbered ones lie over bones. The Verdan zones are depicted in Figure 4.8. This classification is important because the pathogenesis, mechanisms of injury, repair strategies, and rehabilitative programs are based on the level of injury. The clinical presentation is likewise important because certain injuries require acute intervention to restore the extensor biomechanics adequately, whereas others can be treated more conservatively.

INITIAL ASSESSMENT Careful assessment and evaluation of the skin overlying the extensor injury is of paramount importance. Traumatic


FIGURE 4.9 Extensor tendon with 10º for the index metacarpal shaft, 20º for the middle, 30º for the ring, and 40º for the small metacarpal shaft is generally recognized as unacceptable and requires surgical fixation.

Indications for surgery ● ● ● ● ● ●

Rotational deformity Index: >10º of dorsal angulation Middle: >20º dorsal angulation Ring: >30º of dorsal angulation Small: >40º of dorsal angulation Shortening >10 mm

Operative treatment An attempted closed reduction is performed under fluoroscopic guidance. Reduction can usually be obtained by longitudinal traction and manual manipulation at the fracture site. Once reduced, fracture fixation depends upon the specific fracture pattern. If an acceptable closed reduction cannot be achieved, then it is necessary to expose the fracture site to remove any anatomic structures that may be blocking reduction. Alternatively, the surgeon may choose to proceed with open reduction and internal fixation (ORIF) in order to allow an earlier return to activities.

FIGURE 5.1 Diagram of collateral recess pinning.

Collateral recess K-wires and transverse K-wires Collateral recess pinning can be used for displaced fractures of the midshaft or base of the metacarpal, for carpometacarpal (CMC) dislocations, or for CMC fracture–dislocations. The metacarpophalangeal (MCP) joint should be placed in 90º of flexion, and a 0.045 inch K-wire placed by hand at the deepest portion of the collateral recess. Appropriate positioning is confirmed using fluoroscopic imaging, and the pin is power-driven retrogradely into the metacarpal shaft, almost co-linear with its long axis (Fig. 5.1). Once the tip of the wire is within the medullary canal, the wire is driven past the fracture site and into subchondral bone at the base of the metacarpal, or into the hamate if the CMC joint is involved. We leave the K-wires outside the skin in the web spaces for easy removal in the office. This procedure is repeated using a second 0.045 K-wire in the opposite collateral recess, thereby obtaining stable fixation. For transverse pinning, a K-wire is passed through the fractured metacarpal into the adjacent, uninjured metacarpal. This technique essentially acts as internal traction, keeping the fractured metacarpal out to length. The first step of this technique is to reduce the fracture as described previously. The fracture is then stabilized by passing two parallel 0.045 K-wires through the affected metacarpal distal to the fracture site and perpendicular to the long axis of the bone. Next, the K-wire is driven into the adjacent, uninjured metacarpal shaft. A third parallel transverse K-wire is passed through the two metacarpals proximal to the fracture site for stable two-point fixation (Fig. 5.2).

FIGURE 5.2 Diagram of transverse pinning of a metacarpal fracture.

Although this technique is best suited for treating the index and small metacarpals, as these ‘border’ metacarpals are most easily accessible to transverse percutaneous pinning, it is still reasonable to use this for middle or ring metacarpals.

Metacarpal and Phalangeal Fractures 63 In the operating room, a sterile dressing is applied, and an ulnar gutter splint is placed with the affected MCP joints in 70º of flexion. At the follow-up visit, the operative dressing is removed and a custom splint is fabricated by the hand therapist, mimicking the operative splint. At 3–4 weeks the pins are removed in the office and the splint is discontinued.

Operative reduction and internal fixation (ORIF) Transverse or short oblique fractures of the metacarpal midshaft are well treated with plating (Fig. 5.3). This mode of fixation is particularly attractive when there are multiple metacarpal fractures, as rigid stability can be obtained to permit early rehabilitation. Using the dorsal approach as previously described, the surgeon retracts the tendon and strips the periosteum just enough to expose the fracture site (Fig. 5.4). A properly sized plate, usually 2.0 or 2.4 mm, is then selected. The screw diameter should not exceed one-third the diameter of the bone. The appropriate number of screws on either

A

side of the fracture is yet to be determined, but we prefer at least two screws proximally and two distally. The plate is placed dorsally and reduced to the bone. In short oblique fractures it is preferable to lag the fracture through the plate. The remaining screws are then placed in neutral mode. For transverse fractures, the plate is fixed to one fracture fragment using two screws placed in neutral mode, and then the fracture is compressed by placing screws in compressive mode in the opposite fragment. The remaining screws are then placed in neutral mode. It is essential to place the screws perpendicular to the plate to prevent rotation when tightening the screws.

Lag screws Long oblique and spiral fractures of the metacarpal midshaft may be fixed using lag screws placed perpendicular to the fracture line. Lag screws are most appropriate for fractures with a length exceeding twice the diameter of the bone. At least two lag screws should be used if the fracture is twice as long as the diameter of the bone. Three lag screws should be

B

FIGURE 5.3 A Comminuted fracture of the middle metacarpal midshaft and ring metacarpal proximal shaft. B ORIF was performed using dorsally placed T-plates.


Fracture site

Locked IM nails are more practical for wounds that are grossly open at the fracture site with bone loss, such as gunshot wounds to the midshaft of the metacarpal. For closed injuries, locked IM nails are impractical because of the amount of soft tissue stripping necessary to obtain exposure. In addition, the use of an outrigger to lock the nails makes this implant more appropriate for use in the index and small metacarpals, rather than the middle and ring metacarpals. Alternatively, pre-bent 0.045 K-wires may be inserted through a drill hole in the proximal metacarpal and passed antegrade across the reduced fracture. Two to three such wires will provide stable fixation with minimal dissection.5,6

Postoperative care A splint is worn for 4 weeks, and protected range of motion exercises are initiated 3–5 days after surgery. K-wires should be removed 3–4 weeks after surgery.

Clinical Pearls and Pitfalls

Extensor tendon

Periosteum

FIGURE 5.4 Exposure of metacarpal shaft fracture.

used if the fracture is three times the diameter of the bone. Three lag screws have 50% more strength than two. As with compression plating, the screw diameter should not exceed one-third the diameter of the bone. With this technique the fracture is exposed as described, and then reduced and clamped in place. Great care is taken when over-drilling the gliding hole to prevent iatrogenic fracture. A safe distance from the fracture edge – at least one diameter of the drill bit – should be maintained when drilling. For screws placed in an oblique orientation to the cortex, countersinking will enhance surface contact of the screw head while minimizing prominence of the head. This latter point may be important to limit irritation of the overlying extensor tendons and soft tissue.

Intramedullary nail The use of locked intramedullary (IM) nails has been described for open comminuted midshaft fractures of the metacarpals.4 This implant requires placement of the nail through the fracture site in antegrade and retrograde fashion, and then locking of the nail proximally and distally using a locking jig.

●

No rotational malalignment can be tolerated in the metacarpals.

●

When using screws, the diameter of the screw should not exceed one-third the diameter of the bone.

●

Two lag screws are appropriate for spiral fractures twice as long as the diameter of the bone.

●

Three lag screws are appropriate for spiral fractures three times as long as the diameter of the bone.

●

Three lag screws enhance fixation strength by 50%.

●

Countersinking the screw head enhances its contact with bone while diminishing the prominence of the hardware.

●

Multiple 0.045 K-wires may be passed antegrade through a proximal drill hole.

METACARPAL BASE FRACTURES Metacarpal base fractures are commonly the result of loading along the long axis of the bone and may present in combination with CMC dislocation. Usually the small metacarpal and the adjacent ring metacarpal are involved. Dislocations may be difficult to assess on plain X-rays owing to overlapping of the metacarpals, particularly on the lateral projection. If this is the case, the oblique view may help delineate fracture patterns and provide more of a true lateral view of the ulnar two metacarpals. A true anteroposterior (AP) view of the ring and small metacarpal may be obtained by taking the image with the hand pronated 30º from the fully supinated position. If the X-ray technician is not familiar with this view, simply order a ‘supination oblique’ radiograph. If the radiographic picture remains

Metacarpal and Phalangeal Fractures 65 obscured, a CT scan will help clarify the distorted anatomy at the CMC joint. The hamate should be inspected carefully to ensure that there is not a shear fracture of the distal portion involving the CMC joint. Isolated extra-articular fractures at the base of the metacarpal that are minimally displaced are usually treated successfully by non-operative means in a well-molded short arm cast or custom splint. The MCP joint should be in 70–90º of flexion, and the remaining joints of the finger may be left free.

Operative treatment Exposure of the CMC joint is through a dorsal longitudinal incision directly over the fracture site, as described for shaft fractures of the metacarpals. It is usually necessary to incise the CMC joint capsule in line with the skin incision to fully expose the fracture, particularly if the fracture is intraarticular. After exposure, the fracture site should be inspected and cleansed of debris (Fig. 5.5) This is also a good time to examine the articular portion of the hamate. Displaced articular fractures of the hamate should be reduced and fixed with lag screws, if possible. Many of the techniques described for treatment of metacarpal shaft fractures also apply to fractures of the metacarpal base.

metacarpals, but the authors do not feel that this is essential if stable fixation is obtained. Postoperatively, the patient is placed in an ulnar gutter splint in the safe position, and early protected range of motion is initiated. The splint is discontinued at 3–4 weeks.

Transverse K-wire pinning In the presence of a small finger CMC dislocation, percutaneous oblique K-wires can be placed without violating the MCP joint capsule. One pin is placed from the ulnar border of the hand across the small finger metacarpal base into the hamate, and a second K-wire is placed from the small into the ring finger metacarpal. The technique is also possible with a ring finger CMC dislocation, but is technically more difficult (Fig. 5.6). After confirming fracture reduction fluoroscopically, the pins are cut below the skin in anticipation for removal in the office. A protective splint is applied in the intrinsic-plus position and discontinued when the pins are removed four weeks after surgery.

Lag screws Long oblique fractures of the base of the metacarpal may be fixed using two, or preferably three, lag screws placed from the dorsum. Care should be taken to place the screws perpendicular to the fracture and to ensure that they remain extra-articular. Some authors advocate plating for border

Extensor digitorum Extensor carpi ulnaris

Joint capsule Hamate

FIGURE 5.5 Exposure of metacarpal base fractures.

FIGURE 5.6 A fracture at the base of the small metacarpal treated with two K-wires into the adjacent metacarpal, and two K-wires into the hamate.

66 Hand and Upper Extremity Reconstruction CMC fractures or fracture–dislocations of the small finger may be treated with a single collateral recess K-wire originating in the ulnar collateral recess, or with an additional transverse K-wire from the small metacarpal to the ring metacarpal. In the operating room a sterile dressing is applied, and an ulnar gutter splint is placed with the affected MCP joints in 70º of flexion. At the follow-up visit the operative dressing is removed, and a custom splint is fabricated by the hand therapist, mimicking the operative splint. At 3–4 weeks the pins are removed in the office and the splint is discontinued.

Clinical Pearls and Pitfalls ●

An adequate reduction must be confirmed before attempting fixation. For CMC dislocations of the ring or small finger, a ‘supination oblique’ x-ray view is essential.

●

Transverse K-wires using two pins distal to the fracture site and one pin proximal to the fracture site, extending from the injured finger into the uninjured metacarpal, are appropriate for extra-articular fractures. For dislocations of the CMC joint, pinning from the small finger into the hamate and small to ring fingers is appropriate.

●

Collateral recess K-wires originating from the radial collateral gutter of the MCP joint in the small finger may be difficult to drive into the body of the hamate, and should be used cautiously with CMC fractures of the small finger.

A

METACARPAL NECK FRACTURES

B FIGURE 5.7 A CMC fracture–dislocations of the ring and small fingers. B The injury is reduced anatomically with collateral recess pinning.

Collateral recess pinning Many of the principles that apply to fixing metacarpal shaft fractures also apply to fixing fractures of the base. When treating the small finger, collateral recess K-wires driven from the ulnar collateral recess of the MCP joint may be driven across the CMC joint into the hamate, if necessary. However, because of the anatomy of the small CMC joint, collateral recess pins originating from the radial collateral recess are likely to miss the hamate. Thus, for extra-articular fractures of the small metacarpal, it is best to drive the K-wire originating from the radial collateral recess no further than subchondral bone at the base of the metacarpal (Fig. 5.7).

Like other fractures in the hand, most metacarpal neck fractures are treated non-operatively. Any rotational deformity is unacceptable and requires correction of the deformity by closed or open reduction. Fractures of the index and middle metacarpal necks are generally treated with splinting or casting if the dorsal fracture angulation does not exceed 15º. Similarly, conservative management is suggested for ring metacarpal neck fractures where dorsal-apex angulation is 30–40º of apex dorsal angulation Small metacarpal: >50–60º of apex dorsal angulation

Operative treatment The operative approach to the metacarpal neck is usually through a dorsal approach, as previously described. The use of the Jahss maneuver renders open treatment unnecessary in most metacarpal neck fractures, with the exception of subacute or chronic fractures that have substantial callus formation.

FIGURE 5.8 Metacarpal neck fracture treated with transverse K-wires.

After fracture reduction, a K-wire may be placed on either side of the head of the fractured metacarpal. Use imaging to ensure that the pins are placed on the lateral nonarticular facets of the bone rather than in articular cartilage. The K-wires are then advanced proximally in an oblique fashion across the fracture and into the cortex of the metacarpal. To increase torsional stability, do not cross the Kwires at the fracture site.

The skin is incised on the ulnar border of the small metacarpal. Take care to protect branches of the dorsal ulnar sensory cutaneous nerve. The extensor carpi ulnaris insertion may be incised longitudinally, and the cortex is perforated using a power drill oriented nearly in line with the long axis of the metacarpal. Prior to intramedullary insertion, the K-wires must be prepared by cutting off the sharp tip: a 30º bend in the wire is made about 5 mm proximal to its distal tip. Removal of the sharp tip and the 30º bend will help prevent perforation of the radial metacarpal cortex. The pins are then inserted through the proximal cortical hole, advanced antegradely across the reduced fracture, and passed into the cancellous bone of the distal metaphysis (Fig. 5.9). The pins are then cut short, and the skin is closed. This technique is technically more challenging than other forms of pinning described.

Bouquet pinning

Open reduction with internal fixation

Bouquet pinning encompasses the use of multiple K-wires passed antegradely through a cortical window in the metacarpal base. These wires are driven across the reduced fracture into the metaphyseal bone in the distal metacarpal, thereby stabilizing the fracture.8 This technique is most amenable to the index and small metacarpals.

The small size of the distal fragment makes it difficult to place more than one fixation screw. If adequate purchase can be obtained in the distal fragment, a dorsal plate will provide stable fixation and permit early rehabilitation. Concern about extensor tendon adhesions is always present, but early movement should reduce the incidence.

Transverse K-wire fixation A similar technique previously described is used. Be wary of translation of the fractured metacarpal head when driving the K-wires. One outcome study showed acceptable outcomes of transverse K-wire fixation of small metacarpal neck fractures7 (Fig. 5.8).

Crossed K-wire fixation


FRACTURES OF THE METACARPAL HEAD Metacarpal head fractures are usually the result of clenchedfist trauma. As with metacarpal neck fractures, open injuries sustained in an altercation necessitate examination of the extensor mechanism and a thorough irrigation and debridement of the joint. Radiographic assessment includes the standard AP, lateral, and oblique views. Additionally, a Brewerton view (dorsal metacarpals flat on X-ray plate, MCP joint flexed 65º, X-ray beam angled 15º radially) can help to delineate fracture patterns.

Curved blunt tip

Operative management

Extensor digitorum Extensor carpi ulnaris

K wire

FIGURE 5.9 Bouquet pinning diagram.

Management of fractures should be tailored to the individual patient, but displaced fractures are indicated for surgical fixation. Varus and valgus competency should be assessed in fracture lines that extend proximally because the fragment may include the collateral ligament origin. As with other metacarpal fractures the surgical approach consists of a dorsal incision, and then midline division of the extensor tendon to gain access to the MCP joint. The synovium and capsule should be dissected off of the bony fragments just enough to provide adequate visualization without compromising vascularity to the fracture fragments. Our preference for fixation is headless bone screws. Countersunk conventional mini-screws can also be used.9 We do not perform percutaneous K-wire fixation through the articular cartilage.

Operative indications A lateral plate must be positioned over the collateral ligaments, which will limit motion at the MCP joint. For these reasons, we discourage the use of lateral plates for metacarpal neck fractures. The authors prefer to use a unicondylar plate in the rare instances when plate fixation is required.

Postoperative care Postoperatively the patient is placed in a splint with the MCP joints in 70º of flexion. The splint is worn for 3–4 weeks with daily range of motion exercises of the hand to limit stiffness. K-wires should be removed 3–4 weeks after the surgery.

● ● ●

Open fractures – ‘fight bites’ Joint incongruity Collateral ligament avulsion fractures displaced more than 2 mm

Headless bone screws Headless bone screws are ideal for intra-articular fractures because stable fixation can be achieved while minimizing damage to the articular surfaces. Several brands are available. A headless screw with variable pitch will create compression at the fracture site and increase stability. If a headless compression screw is not available, a conventional mini-screw can be used. Countersinking the screw head well beneath the articular surface will protect the cartilage. The head of the screw should be placed in a non-articular area. Early range of motion exercises are initiated, and the splint is discontinued 3–4 weeks after surgery.


Make sure that K-wires cross each other proximal to the fracture.

●

When using transverse K-wire fixation, beware of lateral translation of the fractured metacarpal head when placing the pins.

●

Unicondylar plates are preferred in the rare instances where plate fixation is required.


The Brewerton X-ray view may help delineate fracture patterns.

●

Take care to avoid devitalizing articular fracture fragments.

●

Headless compression screws are ideal for fixation.

Metacarpal and Phalangeal Fractures 69

PHALANGEAL FRACTURES Numerous fracture patterns of the phalanges have been described. For the sake of brevity, we have chosen only to discuss the treatment of common injuries, or of unique, complex injuries. Many of the fixation principles described for the treatment of metacarpal fractures also apply for the phalanges, and the section on metacarpal fractures will be referenced when appropriate.

Operative approach Operative treatment of phalangeal fractures is performed with the patient in the supine position using a hand table. Local, regional, or general anesthesia is appropriate. The incisions and approaches may be placed straight dorsal, dorsolateral, or mid-axial, depending on the fracture location and characteristics.

Operative indications ● ● ● ● ●

●

Open fracture Concomitant neurovascular injury requiring repair Malrotation Intra-articular displaced fracture Unstable fracture ● >10º of angulation ● 1 mm is indicated for open reduction and internal fixation. The patient will present with swelling, pain, and limited motion in the PIP joint. It is imperative that true AP and lateral X-rays are obtained to confirm the diagnosis.

Operative exposure A dorsal curvilinear incision is made over the joint. The interval between the central slip and the lateral band is made (Fig. 5.16) and the capsule incised and the hematoma removed. The collateral ligament attachment to the condyle must be preserved to prevent avascular changes to the condyle. If only one condyle is fractured, the fracture is reduced to the intact portion and held in place with a Kwire. Fixation is obtained with preferably two lag screws across the fracture site (Fig. 5.17). The screws are usually 1.5 mm, and one of these must be put through the collateral ligament attachment. Occasionally there is insufficient room for two screws, and one screw and a K-wire are placed. If both condyles are fractured, then a unicondylar plate should be placed laterally after temporary fixation. Dorsal T-plates will be insufficiently stable to begin active movement and can lead to more stiffness.

PIP fracture–dislocation Fracture–dislocation at the PIP joint is one of the most difficult treatment entities in hand surgery. This injury usually occurs with the PIP joint in some degree of hyperextension, followed by axial loading, such as in ball-handling sports. Longitudinally directed forces contribute to the volar lip shear–fracture component that is frequently seen.


A

B

Central slip Lateral band

Collateral ligament

C

K-wire

D

FIGURE 5.16 Dorsal exposure of the PIP joint between the lateral band and central slip.

PIP fracture–dislocations are classified as stable or unstable. The major distinguishing feature between these two types of injury pattern is the presence or absence of intact collateral ligaments. In stable fracture–dislocations, the collateral ligament insertions remain intact. The fracture pattern through the volar lip of the base of the middle phalanx does not disrupt the insertion of the collateral ligaments. In addition, the fracture does not exceed 40% of the volar articular surface. Unstable fracture dislocations involve fractures through more than 40% of the volar articular arc, or when there is disruption of the collateral ligaments. The collateral ligament insertion remains attached to the volar fracture

fragment of the middle phalanx, and the remainder of the phalanx dislocates dorsally. Successful closed reduction of this injury pattern is unlikely. It is often difficult to see subtle subluxation of the joint after these injuries. ‘True’ lateral radiographs are mandatory! The ‘V sign’ is seen with subluxation of the joint. Do not be fooled into thinking that just because the fracture of the base of the middle phalanx involves less than 40% of the articular surface, the joint is stable (Fig. 5.18).

Dorsal blocking splint Stable PIP fracture–dislocations can be treated with closed reduction followed by the application of a dorsal blocking splint. The PIP joint is inherently more stable in flexion,


FIGURE 5.18 A PIP fracture–dislocation, demonstrating the dorsal ‘V’ sign.

FIGURE 5.17 Three screws across a unicondylar fracture of the proximal phalanx.

and the joint should be splinted in the degree of flexion that prevents subluxation. After 3 weeks, we recommend discontinuation of the splint, with initiation of range of motion exercises to prevent stiffness.

External fixation An unstable injury with a comminuted volar lip can be treated using external fixation (Fig. 5.19). This method employs ligamentotaxis to apply traction to the soft tissue envelope, thereby indirectly reducing the fragments. Generally the authors prefer indirect means of reduction through external fixation, rather than proceeding with open reduction and internal fixation. Several dynamic external fixators have been described. Variations include outrigger splints,13 intraoperatively fabricated devices using K-wires and rubber bands, and commercially available constructs. The key to dynamic external fixation is that the center of rotation is at the isometric

FIGURE 5.19 A commercially available external fixator.


A

B

FIGURE 5.21 ‘Shotgun exposure’ for volar plate arthroplasty. A The joint is shotgunned open. B Volar plate is interposed into fracture. C Lateral radiograph with joint reduced.

FIGURE 5.20 ORIF of volar plate avulsion fracture. A Shotgunned open with fracture exposed. B Fixation of fracture with two screws.

point on the head of the proximal phalanx and the joint is reduced anatomically. Agee14 has described a force coupling device most useful for fracture dislocations in which at least 50% of the dorsal portion of the middle phalanx is intact. It is beyond the scope of this chapter to review the technique. Dynamic longitudinal traction is most useful to treat comminuted fractures of the base of the middle phalanx. Schenck13 described this useful technique. Finally, there are commercially available external fixators that can stabilize the joint in a reduced position and/or provide longitudinal traction. External fixation allows immediate range of motion at the PIP joint. These frames require significant expertise to apply, but can be quite useful. External fixators are generally left in place for 4–6 weeks, during which time active range of movement exercise is allowed. Usually, the patient requires the services of a certified hand therapist to aid in ranging motion.

Open reduction with internal fixation Unstable fractures with a single, large fracture fragment may be amenable to ORIF.15 A volar approach using a Bruner incision is made over the PIP joint, and the joint is then exposed through the interval between A2 and A4 pulleys in the flexor sheath. The profundus tendon is retracted laterally while the superficialis is split longitudinally, and the volar plate is usually still attached to the volar fragment from the base of the middle phalanx. An indirect reduction of the joint is performed (Fig. 5.20). The accessory collateral ligaments are incised sharply and the joint is ‘shotgunned’ open. The fracture is reduced and temporarily fixed in its proper position using K-wires. The wires are then exchanged for screws, taking care to ensure that the screws do not interfere with either flexor or extensor tendon excursion. If fracture reduction is not feasible, then volar plate arthroplasty or hemihamate reconstruction remain viable alternatives with this approach.

Volar plate arthroplasty The same approach as described for ORIF is used for volar plate arthroplasty (VPA). In the ‘shotgunned’ position

the fracture fragments and non-viable bone are removed from the volar lip of the proximal phalanx to create a defect that can accommodate the thickness of the volar plate (Fig. 5.21).16 A running suture is then placed in the volar plate, starting at the distal lateral margin. The stitch is advanced proximally along the lateral edge of the volar plate, crossed over the proximal edge of the volar plate to the contralateral edge, and then advanced distally. Many authors prefer an absorbable suture to prevent difficulty with the suture postoperatively. Drill holes are then made starting in the dorsal edge of fracture line on the base of the middle phalanx and directed dorsally. The two ends of the suture, from either side of the volar plate, are passed through the drill holes and tied dorsally over a padded button with the PIP joint in extension. Alternatively, mini bone anchors can be used to sew the volar plate into place. The volar plate should now cover the articular surface of the proximal phalanx. Some authors advocate bone grafting ‘behind’ volar to the volar plate, but the authors feel this is not necessary. Finally, a 0.045 Kwire is used to transfix the joint in about 20º of flexion for 2 weeks, at which time range of motion exercises can be initiated. The pullout suture and button are removed 4 weeks postoperatively.

Hemihamate arthroplasty When there is insufficient bone stock to support VPA, a hemihamate arthroplasty is an alternative salvage procedure.17 The same ‘shotgun’ approach is used for ORIF and VPA. A trough at the volar base of the middle phalanx is prepared to receive the hemihamate autograft (Fig. 5.22). This is obtained through a dorsal incision on the affected hand centered over the fourth and fifth CMC joints. The graft incorporates the dorsal 50% of the hamate, and extends radially and ulnarly such that it includes 50% of the articular width of the fourth and fifth CMC joints, respectively. The graft is then trimmed so that it fits into the phalangeal defect, replicating the native articular surface, and secured in place using two or three mini-screws. The volar plate is repaired to its distal insertion. The finger is splinted for 3–5 days, and then early active motion is initiated.


B

A

FIGURE 5.22 A PIP fracture of the volar lip. B The joint is ‘shotgunned’ open and the hamate graft fixed to the volar lip of the middle phalanx with two lag screws. Note that the middle phalanx is toward the bottom of the picture. C Lateral radiograph of hemihamate autograft in place.

C



PIP fracture–dislocations are classified as stable or unstable, depending on the amount of collateral ligament attached to the fracture.

●

It is crucial that a true lateral radiograph be obtained to confirm a concentric reduction of the joint.

●

Stable injuries can be treated closed with a dorsal blocking splint.

●

Unstable injuries are indicated for operative fixation.

●

External fixation is usually the first choice of treatment.

●

Single, large fracture fragments are amenable to ORIF.

●

Irreparable fractures of the volar lip of the middle phalanx are well treated with VPA or hemihamate arthroplasty.

COMPLICATIONS Scar formation is a potential complication with injuries to the hand. Extensive scarring can occur in the skin, the tendons, or the joint capsule. The goal of early range of movement protocols is to limit the degree of scarring and preserve motion. Aggressive therapy, such as tendon gliding, scar mobilization and joint mobilization are essential to preserve motion. Scars that are unresponsive to therapy may be indicated for surgical release of the skin, tendon, or joint. Malunion is most common with fractures treated nonoperatively. Shortening, angulation, and malrotation are possible. The presence of scissoring as the patient makes a fist is consistent with malrotation. One cadaveric study found that metacarpal shortening is related to loss of power, with 10 mm of shortening corresponding to 45% loss of power.18 Symptomatic malunions should be corrected by osteotomy.19 Non-unions of the hand are rare, with a reported incidence of contralateral thumb in full extension and 30º of flexion ● Valgus laxity of 30º in full extension and 30º of flexion ● Instability after 4–6 weeks of casting ● Persistent pain after 4–6 weeks of casting ● Open injuries ● Combined injuries (flexor tendons, more involved fractures, etc.) Contraindications Attritional instability/chronic laxity ● Late presentation of acute injuries (requires reconstruction) ● Significant arthritic changes to MCP joint ●

E

In 1963, Stener4 described what would come to be known as the ‘Stener lesion’ (Fig. 6.2). He found that 25 of 39 cases of complete UCL rupture involved both the proper and accessory ligaments, where the adductor aponeurosis had become interposed between the distal end of the avulsed ligament and its insertion into the proximal phalanx (see Fig. 6.4C). He accurately concluded that healing after any length of immobilization or rehabilitation would result in chronic laxity. The presence of a Stener lesion almost definitely indicates a need for surgical treatment, whereas its absence suggests good healing with immobilization.

FIGURE 6.2 Stener lesion. The Stener lesion results from a severe valgus force applied to the thumb metacarpophalangeal joint (MCP). A The normal relationship of the adductor aponeurosis to the UCL. B A moderate valgus force may cause the UCL to be partially torn, but it will not displace proximal to the adductor aponeurosis and will heal without surgical intervention. C A greater valgus stress will cause the UCL to be displaced proximal to the aponeurotic edge, but remain attached to the metacarpal head. D The UCL will remain displaced after the valgus stress is relieved. E Clinically, the Stener lesion appears as a hemorrhagic tendon edge (white circle) proximal to the adductor aponeurosis (white lines). Note the branch of the radial sensory nerve dorsal to the incision (blue arrow).

Thumb Ulnar Collateral Ligament Repair Techniques 81

INDICATIONS AND CONTRAINDICATIONS The presence of a Stener lesion is an absolute indication for surgery. Interposition of the adductor aponeurosis between the ruptured collateral ligaments precludes successful healing of the ligament to restore stability. The accurate identification of a Stener lesion is difficult preoperatively, but it occurs with such frequency after rupture of both the proper and accessory collateral ligaments (approximately 80% of cases5) that this finding alone is an indication for surgery. Conversely, if one of the ulnar collateral ligaments is intact, the adductor aponeurosis cannot interpose between the ruptured ligaments and the injured ligament will be in anatomic proximity to its insertion. This is an incomplete rupture and good outcomes can be achieved without surgery.6 Other indications for surgical treatment include open avulsion injuries, lacerations, combined injuries with flexor or extensor tendon lacerations, and patients who have failed immobilization with persistent pain or instability. Contraindications to surgical repair of the UCL include chronic attritional instability, significantly late presentation of acute tears, extensive MCP joint arthritis, and patients with significant medical comorbidities. In patients with delayed presentation consideration should be given to, and consent obtained for, a ligamentous reconstruction with tendon graft in case the UCL is insufficient for primary repair.

PREOPERATIVE HISTORY AND CONSIDERATIONS The key to treating patients with acute UCL injuries is accurately determining when a Stener lesion is present. Most agree that the history and physical examination (Fig. 6.3) provide enough information to make this determination. Patients can often recall direct trauma to the thumb; however, this may not be the case in more complex accidents, such as skiing or motor vehicle accidents. It is important to question the patient about previous injuries or

FIGURE 6.3 Physical examination.

pre-injury symptoms, as acute-on-chronic injuries should be managed as an acute injury. The initial examination is difficult in most patients who present within days of the injury because of pain and swelling. Evaluation may be facilitated with a local anesthetic block or joint injection to allow a more thorough examination. However, this is not practical in many situations. The use of anesthetic agents can increase swelling, making evaluation difficult. It may be better to immobilize the patient for 7–10 days in a thumb spica splint and re-examine them after some of the pain and swelling has resolved. At this time the laxity is easier to appreciate as the patient guards less and allows a more complete examination. A palpable mass may be present along the metacarpal that suggests a Stener lesion. Laxity of the MCP joint with radially directed stress is the hallmark diagnostic feature of complete UCL tears. The metacarpal head should be stabilized with one hand while stress is applied to the distal aspect of the proximal phalanx. The proper ligament should be tested with the MCP joint in 30º of flexion. Conversely, the accessory ligament is isolated with the MCP joint in full extension. Many different parameters have been suggested to represent a positive finding. Smith and Peimer6 used 45º of laxity in both flexion and extension. Osterman et al.8 suggest 40º of extension and 20º of flexion, and Glickel et al.9 used 30º of both flexion and extension. We believe that at least 30º of laxity in both flexion and extension is necessary, along with at least 15º of laxity more than the contralateral normal thumb in both flexion and extension. Comparison with the contralateral thumb is critical for an accurate diagnosis. The variability in joint laxity can be quite wide, and the quality of the laxity should also be evaluated. A firm endpoint may indicate partial rupture or sprain, whereas a soft endpoint is more typical of complete ruptures. Imaging may also play a role in the management of acute UCL injuries but should only serve as an adjunct to physical examination. Classically, radiographs are obtained before stressing the joint to avoid displacing a non-displaced fracture. However, if ligament displacement did not occur during the violent, uncontrolled initial injury, it will not occur during gentle controlled stressing during examination.6 Posteroanterior, lateral, and oblique plain radiographs may reveal avulsion fractures, most commonly of the ulnar base of the proximal phalanx. Avulsion fractures of any size may occur concomitantly with either incomplete or complete UCL ruptures. In most cases the injuries are ligamentous only, and radiographs may be normal. In grossly unstable joints with complete ligament ruptures radial subluxation may be seen on the posteroanterior view, whereas volar subluxation may be seen on the lateral view. Comparison views of the contralateral thumb are useful, as subtle incongruity of the thumb MCP joint may be a normal variant. Other imaging modalities such as arthrography,10 ultrasound,12 and MRI13 have been used but are typically unnecessary. If additional imaging beyond plain radiographs is desired, MR arthrography is more sensitive than either conventional arthrography or standard MRI.14

82 Hand and Upper Extremity Reconstruction Terminal branches of radial sensory nerve

B

UCL stump

A

C

Extensor aponeurosis

Suture anchor

D

Proper ulnar collateral ligament

For partial UCL injuries, immobilization in a thumb spica cast for 4–6 weeks is recommended. More reliable patients may be placed in a removable thumb spica splint, but non-compliant patients may require full-time casting. At 4 weeks these patients should follow the same protocol as outlined below for surgical patients.

OPERATIVE APPROACH Surgical repair may be performed with use of a regional anesthetic (axillary or Bier blocks) with or without sedation or under general endotracheal anesthesia. A curved longitudinal or lazy S-shaped incision is made over the dorsoulnar border of the thumb, centered at the level of the joint (Fig. 6.4A). The central curve of the incision should run parallel to the joint and extend volarly and distally along the ulnar midaxial line. The terminal branches of the superficial radial nerve, which innervate the dorsoulnar aspect of the distal thumb,

FIGURE 6.4 Surgical approach for UCL repair and reconstruction. A An S-shaped incision is planned with the distal portion more volar to gain better access to the volar proximal phalanx and the anatomic insertion of the UCL. B Beneath the first layer of adipose tissue the branches of the radial sensory nerve are identified and retracted. C The adductor aponeurosis covers the ulnar aspect of the joint, but with a Stener lesion the proximal stump of the UCL can be seen proximal to the proximal edge of the aponeurosis. D The adductor aponeurosis is incised slightly volar to the extensor pollicis longus tendon for lateral repair. A stay suture helps to identify this thin tissue layer and assists in retraction. The ulnar collateral ligament can be visualized beneath the aponeurosis and is repaired to its anatomic insertion site (marked).

should be adequately dissected and gently retracted to prevent traction injury (Fig. 6.4B). Patients should be made aware preoperatively of the possibility of numbness or dysesthesias after simple retraction of this sensitive nerve. The terminal branches pass distally and longitudinally on each side of the dorsolateral aspect of the MCP joint, deep to the subcutaneous fat. After deeper dissection through the subcutaneous fat, the adductor aponeurosis will be visible attaching to the extensor expansion superficial to the joint (Fig. 6.4C). If a Stener lesion is present, its round, hemorrhagic distal end seen in cross-section will be flipped up into the subcutaneous fat proximal to the edge of the aponeurosis. Incise the adductor aponeurosis longitudinally about 3 mm volar and parallel to the ulnar border of the EPL tendon, leaving a cuff to facilitate later repair (Fig. 6.4D). A suture can be placed through the volar flap of the aponeurosis to facilitate later repair at the conclusion of the case. Reflect the aponeurosis ulnar volarly to allow visualization of the ulnar aspect of the joint. Examine the condi-

Thumb Ulnar Collateral Ligament Repair Techniques 83 tion of the joint capsule and the joint itself: small loose articular fragments in the joint should be removed. Signs of arthritic changes should also be inspected for now, as outcomes will be predictably worse when there is preexisting arthritis. The ligament can be reduced back into its anatomic position. Tears in the middle two-thirds of the ligament, albeit rare, may be repaired primarily using a non-absorbable synthetic suture with horizontal mattress or interrupted figure-of-eight sutures. More often, the distal end of the ligament is avulsed from the proximal phalanx and requires repair to its normal insertion site.

Bone anchor technique Repair of the UCL with a bone anchor is an accepted technique that yields good clinical results.15 Following the approach detailed above, the ligament is approximated to the base of the proximal phalanx at its normal anatomic insertion site. This site is marked for bone anchor placement. Any soft tissues or remnant of UCL present in this region is debrided with a rongeur or elevator. A bony bed is preferred for tendon healing, although cortical bone should not be removed as it may weaken the bone anchor holding strength. The bone anchor hole is drilled in the ulnar base of the proximal phalanx volar to the axis of the joint, roughly 3 mm distal and dorsal to the volar aspect of the proximal phalanx. This is near the anatomic insertion of the UCL proper (see Fig. 6.1) The bone anchor is carefully advanced into the predrilled hole. Harley et al.16 showed in vitro that anchor pullout occurs at significantly weaker loads to failure than suture or tendon repairs. In other words, the anchor is typically the ‘weakest link.’ An 0 or 2/0 braided suture pre-threaded though the bone anchor is used to repair the UCL. One limb of the suture is placed through the tendon in a locked loop, and the other limb is placed through in an unlocked fashion. This allows the tendon to be slid down on the unlocked limb to appose the ligament closely to the bone. It is important that the ligament has good bony contact. Alternatively, a pullout suture technique may be used to fasten the ligament to its anatomic insertion site. If a fragment of bone is avulsed with the ligament from the proximal phalanx, its treatment depends on the size of the fragment. If small (no more than 10% of the articular surface) the fragment and the ligament should be secured into the defect with either a bone anchor or a pullout suture. Larger fragments should be reduced and fixed anatomically with a pullout suture, K-wire, or mini-fragment screw. After UCL repair with a suture anchor or a pullout suture, any capsular tear that can be repaired is approximated with a 2/0 braided non-absorbable suture (Fig. 6.5). However, there is not always sufficient tissue for this. Care should be taken to ensure that the extensor tendon or aponeurosis is not incorporated into this repair, as it will limit tendon motion postoperatively. Another suture should be secured between the volar aspect of the ligament and the volar plate to recreate this complex.

A

B FIGURE 6.5 Repair of acute UCL injury with a pullout suture. A A Keith needle is drilled through the base of the proximal phalanx at the attachment site of the torn proper UCL. In hard bone, the path is predrilled with a Kirschner wire. B A monofilament suture is placed through the distal stump of the UCL. These sutures are pulled through the base of the proximal phalanx and out through the radial skin. The sutures are placed through a padded button and tied. The ulnar side is visualized as the sutures are tied to be certain that excellent contact is achieved between the ligament stump and the bone.

Following the ligament and capsule repair, the joint should be gently checked for stability. This should be done under fluoroscopy to better assess subluxation. If there is still substantial laxity, or if the repair is tenuous, a 0.045 in K-wire should be placed across the MCP joint with the proximal phalanx in slight ulnar deviation. A tenuous repair can occur because of poor tissue quality of the UCL remnant or poor quality of bone holding the bone anchor. The adductor aponeurosis is repaired with an absorbable suture. This is done with a buried figure-of-eight configuration, as the knots can be prominent and bothersome. The skin is closed with interrupted non-absorbable sutures. A plaster thumb spica splint with the IP joint free is placed,

84 Hand and Upper Extremity Reconstruction with care taken not to mold the cast with a radial or abduction stress on the MCP joint. At 10–14 days the splint is removed and cast immobilization is continued for 2–3 more weeks. The cast is then removed and replaced with a removable splint. This amounts to about 4 weeks of strict immobilization postoperatively.

Pullout suture technique A pullout suture may be used to fix the avulsed ligament. A synthetic non-absorbable monofilament suture such as 3/0 nylon or a stainless steel wire is secured into the stump of the UCL via a modified Kessler technique. Care is taken not to lock the suture, as this would prevent pullout when the ligament has healed. A curette or small rongeur is used to remove a little of the bone at the reattachment site in the same anatomic location as described previously for bone anchor placement. Next, two Keith needles are drilled transversely through the decorticated site ulnoradially to exit percutaneously on the radial side of the thumb. While holding the thumb in slight flexion and in a slightly ulnarly deviated, overcorrected position, tension is applied until the ligament is pulled into the shallow trough created in the ulnar base of the proximal phalanx. The sutures are secured to the pullout Keith needles and are tied over a rubber catheter or padded button on the radial side skin surface. Preferably, the skin between the ends of the Keith needles is incised to expose the opposite cortical bone and the sutures are tied on the bone to reduce the discomfort of having the rubber catheter impinging on the skin.

Optimizing outcomes ●

●

●

● ●

●

●

●

Dissect out and protect terminal branches of the superficial radial nerve. Place bone anchor or pullout suture hole at anatomic insertion site over the base of proximal phalanx. Stress repair under fluoroscopy to ensure stability of repair and joint congruity. Repair capsule and ligament/volar plate complex. Be prepared for ligament reconstruction with tendon graft in late presentations, as ligament tissue may be insufficient. Immobilize in splint or cast in neutral position without radial or abduction stress, with IP joint free. Encourage motion at the IP joint to prevent extensor tendon adhesions and stiffness. Begin range of motion exercises by 4 weeks.

COMPLICATIONS AND SIDE EFFECTS The most commonly encountered complications of UCL repair are postoperative radial sensory nerve deficits. These are usually transient, frequently resolving before the sutures are removed. The symptoms can be painful, however, and patients should be made aware of the potential problem with simple traction alone. True nerve injuries and symptomatic neuromas should be rare, as the anatomy in this region is very predictable.

As with any instability surgery, the most worrying complication is persistent or recurrent instability. Stiffness, however, is probably more common. Reinserting the UCL too far dorsally may lead to instability, particularly in flexion. An excessively distal insertion leads to over-tightening. Prolonged immobilization can also lead to stiffness, although this is usually preferred to recurrent instability, as functional deficits are minimal with MCP joint stiffness.

POSTOPERATIVE CARE After 10–14 days the splint and non-absorbable sutures are removed. A thumb spica cast is placed, again leaving the IP joint free, and motion at the joint is encouraged. The patient returns in 3–4 weeks for removal of the cast. A forearmbased removable splint is applied and is removed for range of motion exercises. Active flexion and extension of the IP and MCP joints and full range of motion of the CMC joint are encouraged under the guidance of a hand therapist. At 7–8 weeks the splint is changed to a hand-based thumb spica splint. Increased splint removal at home to perform simple activities such as zipper manipulation and buttoning is allowed. The therapist initiates flexion of the IP joint and thumb adduction against light resistance. Wrist and forearm strengthening exercises are also begun. By week 10, near complete active range of motion should be achieved, with specific therapy directed towards correcting these deficits. Pinch should be 60–70% of contralateral strength, with restrictions still placed on activities that place radial force on the tip of the thumb. The splint may be discontinued except in higher-risk locations (work, outdoors, etc.). Full activity is allowed at 3 months, with the exception of contact sports, which are prohibited for another month. Taping or semi-rigid splinting of the MCP joint should be applied when play resumes.

CONCLUSIONS Acute injuries to the ulnar collateral ligament of the thumb MCP joint result from a violent valgus stress. Pain on the ulnar side of the MCP joint, swelling, and instability to valgus stress suggest injury to the UCL. If the joint is unstable to valgus stress with the MCP joint in both extension and flexion, a Stener lesion is probably present, necessitating surgical repair of the UCL. During operative repair, the ruptured UCL is fixed in its anatomic location by securing the distal end to either a bone anchor or a pullout suture. Four weeks of postoperative immobilization is followed by progressive range of motion and resistance exercises under the supervision of the surgeon and therapist. By 3 months the results are typically good to excellent, with strength and motion close to those of the uninjured hand.

CHRONIC UCL INJURY REPAIR Gamekeeper’s thumb is the classic term coined by Campbell1 in 1955 to describe chronic attritional laxity of the thumb ulnar collateral ligament. Most cases of chronic

Thumb Ulnar Collateral Ligament Repair Techniques 85 BOX 6.2 Indications and contraindications for chronic ulnar collateral reconstruction Indications ● Attritional UCL insufficiency (repetitive stress) ● Injuries over 6 weeks old ● Failed acute repairs ● Open injuries with deficient ligament tissue Contraindications MCP arthritis ● Open injuries with contamination ●

UCL deficiency encountered by hand surgeons today are the result of untreated or unsuccessfully treated acute injuries, rather than subacute repetitive stress such as that endured by the Scottish gamekeepers. Lesions are typically considered chronic at 6 weeks after acute injury. Helm et al.17 showed that the older a lesion is, the less likely it is that stability can be achieved by anatomic repair as described for acute rupture.17 When a patient presents 3 weeks or more after an acute injury, ligament reconstruction should be considered and discussed.

INDICATIONS AND CONTRAINDICATIONS Ligament reconstruction is required in all cases of chronic instability, whether it be attritional rupture, late presentation of acute injuries, or unhealed treated acute injuries. Whereas it is easy to make the decision in patients who present 3 months after injury, it is harder when they present between 3 and 8 weeks after acute injury. Although successful primary repairs have been reported, the results are poorer as time elapses.9 The greatest contraindication to UCL reconstruction is MCP arthritis. Radiographic evidence of arthritis is a contraindication to the repair or reconstruction of UCLdeficient joints. In these patients, MCP joint fusion is the preferred treatment. In patients with early radiographic changes or very chronic injuries, preoperative discussions should focus on possible joint fusion, as intraoperative joint inspection may show more advanced degeneration. In these patients, reconstruction will lead to a stiff painful joint that will probably progress to fusion at a later date.

PREOPERATIVE HISTORY AND CONSIDERATIONS Patients with chronic deficiency of the UCL typically present with thumb weakness, pain, and swelling. Weakness and instability are the most common complaints, exacerbated when trying to grasp large objects or during torsional movements such as unscrewing a jar.9 The patient can usually recall a specific acute injury event. The examination of chronic UCL injuries is similar to that for acute injuries, with a few key differences. Gross volar subluxation, diffuse MCP swelling, or radial deviation on inspection are observations characteristic of chronic

deficiency of the UCL. There is gross instability without a defined endpoint. Crepitus with active motion is the most specific examination sign of arthritis. Radiographic evaluation with posteroanterior, lateral, and oblique views is imperative to rule out degenerative changes. The joint can again be evaluated for radial deviation and volar subluxation, which is made easier by comparison with the other hand.

OPERATIVE APPROACH The anesthesia, positioning, incision and surgical approach for UCL reconstruction are the same as for acute repair (see above).

Suture anchor technique The authors prefer a method of repair similar to that described by Mitsionis et al.18 The remnants of the proximal and distal ligaments are isolated and preserved, with roughening of the bone at the insertion sites. There is frequently little ligament tissue remaining distally, but the proximal stump can supplement the proximal attachment of the graft. A hole is drilled at the roughened anatomic insertion sites and a bone suture anchor with a 2/0 suture attached is placed. We prefer bioabsorbable anchors. The sutures are pulled upon to set the anchor and test its stability. In cases with osteoporotic bone we have had success using larger anchors with larger sutures when the smaller anchors have pulled out. Alternatively, a larger anchor can be used, but the larger suture (usually a number 2) can be exchanged for smaller suture material more appropriate for the UCL ligament. A sufficient length of palmaris longus tendon is harvested using two 5 mm transverse incisions, one at the volar wrist flexion crease and one near the musculotendinous junction. A tendon stripper of the appropriate size, if available, can be used through a single distal incision. In the absence of the palmaris longus, a strip of the flexor carpi radialis or the abductor pollicis longus may be used, although a more extensile approach is required to safely harvest these tendon grafts. The suture of the proximal bone anchor is passed through a free end of the graft via a mattress suture. One limb of the suture is locked through the tendon and the other is allowed to slide to permit good tendon–bone apposition. If an intact proximal remnant of the UCL is present, the graft is reinforced through a slit made in the remnant and then secured to the distal bone anchor, as shown in Figure 6.6.

Bone tunnel technique Two holes 3 mm in diameter are made at roughly the 1 and 5 o’clock positions on the ulnar side of the proximal phalanx. The holes are progressively deepened with a small curette, aiming obliquely towards each other to meet in the medullary canal. Care must be taken to keep the holes sufficiently far apart – at least 5 mm – to maintain a stable bone bridge (Fig. 6.7).

86 Hand and Upper Extremity Reconstruction 7 mm

UCL remnant

3 mm

3 mm 3 mm 5 mm

8 mm

3 mm

4 mm 5 mm

A

B

Tendon graft

UCL remnant sewn over tendon graft

FIGURE 6.6 Chronic UCL reconstruction with suture anchors. A A suture anchor is placed at the origin of the UCL under the remnant of the torn ligament. A second anchor is placed at the site of the normal insertion of the proper UCL. A tendon graft (TG) is harvested for reconstruction. B The proximal attachment is sewn in first and is placed through a slit in the base of the UCL remnant to reinforce the repair. The distal end of the tendon graft is sewn second in order to set the tension.

Another gouge is placed at the ulnar concavity of the metacarpal head corresponding to the origin of the UCL.19 This hole should be slightly larger – roughly 4 mm – as both ends of the graft will be passed through this tunnel. It should be directed dorsoradially to exit the radial cortex and emerge subcutaneously on the radial side of the thumb. A small incision is made at this location. A 28-gauge steel wire is passed radioulnarly through this incision and bone tunnel to emerge through the ulnar cortex of the metacarpal head. Next, another wire is passed through one of the holes in the proximal phalanx and out the other. A tendon graft is harvested as described for the previous method. The narrowest end of the graft is secured to the wire passed through the proximal phalanx tunnel and passed through this tunnel by traction on the wire. Next, the wire passed through the metacarpal tunnel is secured to the other free end of the graft, and both ends are passed ulnoradially through the metacarpal head and out the radial side of the thumb. Tension on the repair is adjusted by traction on the wires. The ends are secured over a felt-backed button or a section of rubber catheter. Alternatively, a suture anchor can be placed on the radial side of the metacarpal head to set the tension on the ends of the graft. To help reinforce either type of repair, the graft is sutured to any local periosteum and capsule using a slowly absorb-

FIGURE 6.7 Bone tunnel placement. Two holes are placed in the base of the proximal phalanx. The tunnels are angled towards each other and connected below the cortex. Care is taken to preserve at least 5 mm of cortical bridge between the two holes. Another hole is placed in the site of the origin of the UCL that traverses the metacarpal head and exits on the radial side.

ing suture such as 4/0 Vicryl. Another suture should be secured between the volar aspect of the ligament and the volar plate to recreate this complex. Further, any defect in the dorsal capsule of the joint should be repaired to prevent future joint subluxation. Lastly, the stability of the repair should be evaluated, as for acute repairs. A radially directed stress should be gently applied to the joint under fluoroscopy to ensure stability. If there is any instability, the authors use K-wire fixation more liberally in chronic reconstruction than in acute repairs. A retrograde 0.045 wire is passed, with anatomic joint reduction assured by fluoroscopy. The adductor aponeurosis is repaired with an absorbable suture and the skin closed with interrupted non-absorbable sutures. A plaster thumb spica splint is placed with the IP joint free, with care taken not to mold the cast with a radial or abduction stress on the MCP joint. At 10–14 days the splint and sutures are removed, and cast immobilization is continued for 4–5 more weeks. At this time it is replaced with a removable splint. Strict postoperative immobilization totals about 6 weeks, 2 weeks longer than for acute repairs. Subsequently, postoperative care and rehabilitation are the same as for acute repairs (Fig. 6.8).


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Dissect out and protect terminal branches of the superficial radial nerve. Preserve at least a 5 mm bone bridge between holes in the proximal phalanx. Stress repair under fluoroscopy to ensure stability of repair and joint. Place 0.045 K-wire through joint to secure anatomic reduction. Repair adductor aponeurosis with slowly absorbing suture. Immobilize in splint or cast in neutral position without radial or abduction stress, and with IP joint free. Encourage motion at the IP joint to prevent extensor tendon adhesions and stiffness. Maintain immobilization 2 weeks longer than for acute repairs.

Thumb Ulnar Collateral Ligament Repair Techniques 87 The chronic lesion is at least 6 weeks old and typically results in instability and pain. The evaluation for a suspected chronic UCL injury is the same as that for acute injuries. When considering operative treatment, one must entertain the option of arthrodesis for patients in need of stability and longevity in return for a reduced range of motion. Operative reconstruction carried out using a free tendon graft can restore stability and function in the unstable thumb.

REFERENCES A

Tendon graft

B FIGURE 6.8 Tendon graft reconstruction through bone tunnels. A One end of the tendon graft is looped through the proximal phalanx. The two ends of the graft are then pulled though the ulnar hole in the metacarpal head to the radial side of the metacarpal. B The tendon ends can be secured using a button or a suture anchor placed on the radial side of the metacarpal head.

COMPLICATIONS AND SIDE EFFECTS As in acute repairs, the most commonly encountered complications of UCL repair are radial sensory nerve deficits postoperatively. Other similarities include continued laxity or instability, stiffness, infection, and continued pain. Progressive arthritis is possible as a result of any of these complications. Most are treated with MCP joint fusion.

POSTOPERATIVE CARE Postoperative care is similar to that for acute repairs. The notable difference is the length of immobilization, 6 weeks of full-time immobilization being required. At this point the pullout suture is removed. Splint wear is recommended for another 6 weeks. Early IP motion is encouraged in the cast, and formal hand therapy is initiated with splint wear. Rehabilitation protocols from this point on are similar to those used in acute repairs.

CONCLUSION Chronic UCL lesions are usually the result of an unrecognized, untreated, or unsuccessfully treated acute injury.

1. Campbell CS. Gamekeeper’s thumb. J Bone Joint Surg Br 1955; 37B: 148–149. 2. Gerber C, Senn E, Matter P. Skier’s thumb. Surgical treatment of recent injuries to the ulnar collateral ligament of the thumb’s metacarpophalangeal joint. Am J Sports Med. 1981; 9: 171–177. 3. Warme WJ, Feagin JA Jr, King P, et al. Ski injury statistics, 1982 to 1993, Jackson Hole Ski Resort. Am J Sports Med 1995; 23: 597–600. 4. Stener B. Skeletal injuries associated with rupture of the ulnar collateral ligament of the metacarpophalangeal joint of the thumb. A clinical and anatomical study. Acta Chir Scand 1963; 125: 583–586. 5. Heyman P, Gelberman RH, Duncan K, Hipp JA. Injuries of the ulnar collateral ligament of the thumb metacarpophalangeal joint. Biomechanical and prospective clinical studies on the usefulness of valgus stress testing. Clin Orthop Relat Res 1993; 292: 165–171. 6. Heyman P. Injuries to the ulnar collateral ligament of the thumb metacarpophalangeal joint. J Am Acad Orthop Surg 1997; 5: 224–229. 7. Smith RJ, Peimer CA. Injuries to the metacarpal bones and joints. Adv Surg 1977; 11: 341–374. 8. Osterman AL, Hayken GD, Bora FW Jr. A quantitative evaluation of thumb function after ulnar collateral repair and reconstruction. J Trauma 19981; 21: 854–861. 9. Glickel SZ, Malerich M, Pearce SM, Littler JW. Ligament replacement for chronic instability of the ulnar collateral ligament of the metacarpophalangeal joint of the thumb. J Hand Surg [Am] 1993; 18: 930–941. 10. Bowers WH, Hurst LC. Gamekeeper’s thumb. Evaluation by arthrography and stress roentgenography. J Bone Joint Surg Am 1977; 59(4): 519–524. 11. Resnick D, Danzig LA. Arthrographic evaluation of injuries of the first metacarpophalangeal joint: gamekeeper’s thumb. AJR Am J Roentgenol 1976; 126: 1046–1052. 12. Hergan K, Mittler C, Oser W. Pitfalls in sonography of the gamekeeper’s thumb. Eur Radiol 1997; 7: 65–69. 13. Hinke DH, Erickson SJ, Chamoy L, Timins ME. Ulnar collateral ligament of the thumb: MR findings in cadavers, volunteers, and patients with ligamentous injury (gamekeeper’s thumb). AJR Am J Roentgenol 1994; 163: 1431–1434. 14. Ahn JM, Sartoris DJ, Kang HS, et al. Gamekeeper thumb: comparison of MR arthrography with conventional arthrography and MR imaging in cadavers. Radiology 1998; 206(3): 737–744. 15. Weiland AJ, Berner SH, Hotchkiss RN, et al. Repair of acute ulnar collateral ligament injuries of the thumb metacarpophalangeal joint with an intraosseous suture anchor. J Hand Surg [Am] 1997; 22: 585–591. 16. Harley BJ, Werner FW, Green JK. A biomechanical modeling of injury, repair, and rehabilitation of ulnar collateral ligament injuries of the thumb. J Hand Surg [Am] 2004; 29: 915–920. 17. Helm RH. Hand function after injuries to the collateral ligaments of the metacarpophalangeal joint of the thumb. J Hand Surg (Br) 1987; 12: 252–255. 18. Mitsionis GI, Varitimidis SE, Sotereanos GG. Treatment of chronic injuries of the ulnar collateral ligament of the thumb using a free tendon graft and bone suture anchors. J Hand Surg [Br] 2000; 25: 208–211. 19. Green DP, Hotchkiss RN, Pederson WC, Wolfe SW. Green’s operative hand surgery. Philadelphia: Elsevier, 2005.

CHAPTER

7

Amputation Grey Giddins and Ilana Langdon

INTRODUCTION Amputation is an infrequent but important operation in hand surgery. Unlike reconstructive hand surgery, this is a destructive operation and usually the last resort. Patient understanding is crucial, as the outcome is often dictated by how they accept/come to terms with their loss and how hard they work to adapt. When possible – and sensible – the length of the digit, especially the thumb, should be maintained for functional and esthetic considerations, but this is not dogmatic because ray amputation of a finger (Fig. 7.1A–C) may give a better result than partial finger amputation (Fig. 7.2A,B). Pain management is critical perioperatively and particularly postoperatively. No amputation is ever truly pain-free, except perhaps in children, and the result of surgery is often directly correlated with the level of pain. Too frequently, amputation is seen as a simple operation that can be undertaken by a junior surgeon or with little attention to detail. A poorly performed amputation can turn a troubled hand into a ruined one, whereas a well performed amputation can often restore considerable function to a disabled hand (Fig. 7.1C).

INDICATIONS AND CONTRAINDICATIONS Absolute indications Malignancy (except for less invasive skin lesions, particularly in the elderly) and avascular digits are absolute indications. A severe infection may become an absolute indication, although more often it is a relative indication.

Relative indications These include severe infections that may be in the soft tissues, such as the pulp or the bone and joint. Other indi-

cations may be conditions after acute trauma, such as an amputated finger that cannot be salvaged, or a partial amputation. An example of this would be a degloving injury or other injuries such as hot press injuries. Complex open trauma with bone and soft tissue damage may not be salvageable and require amputation. Common relative causes are disabling deformity, for example stiffness after trauma reconstruction, recurrent Dupuytren’s contracture, or persistent pain. Other less frequent causes include benign neoplasia, such as haemangioma, particularly multiple recurrences, metabolic conditions, such as gout, and rarer causes, such as macrodactyly.

Contraindications The only definite contraindication is psychological, for example a patient in whom it is felt that even a successful amputation will give a bad result by turning a non-surgical problem into a surgical one. Extra efforts should be made to save the fingers in children and young women. In certain specialist occupations and cultures, for example in the Far East, even partial loss of a digit is a great stigma.

PREOPERATIVE HISTORY AND CONSIDERATIONS Acute injuries The history is usually clear following an accident or a latrogenic complication that results in a vascular problem in the digits or hand. If there is doubt about the viability of the digit, then either surgery should be attempted or the patient’s condition optimized to see whether the blood flow will improve. The patient should be kept warm and well hydrated, with the fingers semi-elevated. This allows good blood supply but also some venous drainage. If the finger

89


A

B

FIGURE 7.1 Index finger ray amputation. The index ray amputation is much more cosmetically appealing than partial finger amputation and is still highly functional.

is unsalvageable, then acute amputation will be in the patient’s best interest for faster rehabilitation. However, the level of the amputation can be difficult to determine because the patient is often not in a position to make an informed judgment. It is better to be too conservative rather than too radical, as further amputation can be performed in the future.

Chronic conditions Occasionally there will be an absolute indication, such as an invasive malignancy. The appropriate operation will be guided by oncological advice and the patient’s functional and cosmetic needs. For most chronic conditions amputation will be one of a number of options. There options include doing nothing, further treatment (such as for a pain condition) and further reconstructive options. All medical treatments should be exhausted prior to considering amputation. However, once amputation is agreed upon, the key decision is the level of amputation. Considerations in the thumb differ from those for the fingers.

Thumb Every effort should be made to preserve thumb length. Loss of the thumb equates to a loss of 50% of hand function and bypassing it, as seen after finger amputation, is impossible. A shorter thumb may require secondary reconstruction, such as skeletal lengthening, deepening of the first web space, or pollicization.

Fingers Finger length should be preserved when possible, provided the amputation is not more proximal than the distal middle phalanx. Because of the intact proximal interphalangeal joint and the superficialis tendon, the finger should continue to be useful for grip and, to a lesser extent, pinch. With more proximal amputation, the finger becomes increasingly less useful and more cosmetically abnormal (Fig. 7.3A,B); a ray amputation should be considered.1 For the border digits, the hand loses some width but often has a reasonable cosmetic appearance after ray amputation (see Fig. 7.1). For the central two fingers (middle and ring), ray amputation will require closing the cleft. This is more dif-

Amputation 91 which gives little functional benefit but considerable cosmetic improvement.

OPERATIVE APPROACH There are three types of digital amputation: tip amputation (terminalization), amputation within the digit, and amputation in the palm, i.e. ray amputation. All have certain steps in common.

Common steps

C FIGURE 7.1, cont’d

The patient must give appropriate consent, and the amputation must be performed in a sterile surgical environment. Although the risk of infection is small in the well vascularized hand, infection in an amputation site can be problematic. One dose of intravenous antibiotics should be given preoperatively, ideally 40 minutes before tourniquet inflation. A second-generation cephalosporin, amoxicillin, flucloxacillin or other equivalent antibiotics are suitable. Metronidazole is unnecessary unless there is unusual contamination. Postoperative antibiotics are not typically required, unless the reason for the amputation is infection. The operation may be performed under local or regional anesthesia. Tip amputations can normally be performed under local anesthetic with a finger tourniquet. More distal digital amputations may be performed with a finger tourniquet, but if more proximal an arm/forearm tourniquet is used. Almost all patients can tolerate an arm or forearm tourniquet for approximately 20 minutes at 250 mmHg. Thus, if two tourniquets are applied, this gives 40 minutes of operating time, which should be sufficient for an experienced surgeon to perform an amputation and closure. Ray amputation requires regional anesthesia.

Tip amputation ficult, and on the ulnar side gives an obvious cosmetic abnormality because of the relative shortness of the little finger compared to the long finger. Ray amputation reduces the width of the palm and can hamper certain manual activities, such as hammering. The alternative is amputation through the proximal phalanx or metacarpophalangeal (MCP) joint. For the border digits (index and little fingers) this gives a greater but still relatively moderate cosmetic abnormality, and retains the width of the palm (Fig. 7.4). For the central digits, amputation at the level of the MCP joint is a major cosmetic abnormality (see Fig. 7.3A) and allowing small objects to escape is a functional nuisance (see Fig. 7.3B). Most surgeons would favor ray amputation of the central fingers, but some patients will have other preferences. It is better to revise the amputation at a later date if the patient is unhappy, rather than removing too much, which cannot be undone. Repeat consultations and illustrative clinical photographs are valuable. For some patients, preservation of even some finger length may permit the attachment of a cosmetic prosthesis,

The typical indication is crush laceration of the fingertip (Fig. 7.5). If there is inadequate soft tissue cover, one can shorten the bone or cover it sufficiently to give a reasonable pad at the end of the digit for pinch. Enough length should be preserved to provide adequate support for the nail. If less than 50% of the sterile nail matrix remains supported, a hook nail deformity often results. In women more efforts may be made to preserve the nail. There are secondary reconstructive procedures that can be performed to help support the nail. With more proximal amputations, the insertions of the flexor and extensor tendons should be maintained. The flexor tendon attaches more distally at the base of the distal phalanx and is more likely to be detached. Preserving the flexor digitorum profundis (FDP) attachment helps to maintain grip strength and active flexion of the distal phalanx remnant. The fingertip is thoroughly debrided and dead or contaminated tissue removed. Prominent bone is trimmed back to approximately 3–4 mm below the surface of the remaining soft tissue of the pulp. If shortening is inadequate, the bone may become prominent as the soft tissues heal and contract. The bone is beveled to provide a flatter


A

B

FIGURE 7.2 Index finger amputation through the proximal phalanx. This is unattractive and gives no functional value except some increased hand breadth. The callosities over only the middle, ring, and little metacarpal heads suggest almost no use of the residual index finger.

surface for pinch. The more dorsal length that can be preserved, the better the support there will be to the sterile nail matrix and nail. This is not an exact science, and clinical judgment and experience are needed. If in doubt, it is better to remove too little bone and revise it later than to remove too much. The skin and soft tissue are loosely opposed as appropriate with an absorbable suture, e.g. 5/0 vicryl rapide. If there is no bone exposed, the soft tissue wound can be treated with dressing changes. This usually gives a better cosmetic and functional result than surgical closure or grafting. Local flaps are rarely indicated in these situations.2,3 After removal of the tourniquet, a nonadherent dressing is applied.

Amputation in the digit This patient (Fig. 7.6A,B) presented with severe infection and joint instability of distal tip of the little finger and elected to have amputation at the level of the DIP joint. Prior to inflating/applying the tourniquet, the skin flaps are marked. It is better to leave the skin flaps longer in order to avoid a more proximal amputation than planned. The only exception is in malignant neoplasia, in which an adequate margin must be achieved first and the closure method

is considered later. The aim of designing the skin flaps is to provide good palmar skin to cover the volar finger, because the palmar skin is thicker, more sensate, and better suited for pinch. In some circumstances there will be much more dorsal skin available. It may be reflected over the volar finger, but this leaves a volar scar that can be tender. Typically the volar skin flap should be marked at least 1 cm longer at the central tip than the planned level of the bone cut. The dorsal flap is typically about 5 mm shorter. The flaps should be planned as gentle sweeping curves from the mid-lateral point (Fig. 7.7). They will also extend proximally about 6–7 mm along the mid-lateral lines of the finger. The dorsal flap is cut straight down to bone, both dorsally and in the mid-lateral line. The extensor tendon is divided transversely at, or just proximal to, the level of the dorsal flap and raised off the bone proximally for approximately 5 mm. If the bone is too long, it is cut carefully with bone cutters and later beveled and shaped using bone nibblers (Fig. 7.8). Volarly the neurovascular bundles and flexor tendons should be identified. The flexor sheath is opened and the flexor tendon(s) pulled distally with the patient’s wrist and digit flexed (Fig. 7.9). The tendon is divided proximally and allowed to retract into the palm. There is

Amputation 93

A

FIGURE 7.3 Middle finger amputation through MCP joint. Like amputation of the index finger through the proximal phalanx, this amputation also leaves a space in the hand where objects may drop through and is cosmetically unattractive.

B

no value in keeping it long. Obviously, if any attachment can be kept, for example FDP to the distal phalanx or flexor digitorum superficialis (FDS) to the middle phalanx, it should be preserved, because it increases flexor power and flexibility in the digit.

Various techniques are described for managing the neurovascular bundles. The artery is divided and cauterized; in the volar flap it should be left long to maximize the blood supply. The nerve is separated from the artery (Fig. 7.10). Some surgeons divide the nerve and suture it dorsally to


FIGURE 7.4 Index finger MCP joint amputation. This amputation yields a better cosmetic result than central digit MCP joint amputations, but is not as cosmetically appealing as a ray amputation.

A

FIGURE 7.5 Fingertip laceration resulting from a crush injury that is repaired using a local flap.

B

FIGURE 7.6 This is similar to a terminalization. This patient presented with a severe infection and joint instability.

Amputation 95

FIGURE 7.7 Conservative skin markings.

FIGURE 7.9 Cutting the FDP tendon short after retraction.

FIGURE 7.8 The bone is carefully cut with bone cutters and later beveled and shaped using bone nibblers.

provide a dorsal neuroma to reduce pinch discomfort volarly (Fig. 7.11). Others cauterize the nerve tip to seal the end in order to reduce neuroma formation. No evidence exists that these techniques reduce painful neuromas. The nerve is divided 5–10 mm proximal to the level of the bone cut. This may leave the tip a little insensate, but this is not typically a problem. The bone end should be shaped to a smooth curve, preferably with a volar bevel. This gives a broader area for pinch and also some tapering for the fingertip to make it less bulbous. Finally, the skin flaps are shaped. They should taper nicely, avoiding a bulbous end to the finger (Fig. 7.12). The key is to have good coverage of the bone with the volar skin and to place the scar dorsal to the fingertip, even if only by a few millimeters. Prior to skin closure we irrigate the wounds thoroughly with saline to reduce bacterial contamination. The edges of the flap are sutured together with 5/0 vicryl rapide, typically with horizontal mattress-type

FIGURE 7.10 and 7.11 Cutting the nerves short but leaving the nerve branch in the volar flap.


FIGURE 7.13 Amputated long finger.

FIGURE 7.12 Tapered skin flaps. (Ray amputation figures provided by D. Shewring). This patient suffered a chronic MCP joint infection and elected to have a ray amputation. These photographs were given by a fellow hand surgeon and therefore show a slightly different procedure from the ones performed by the author.

everting sutures. The flaps should be sutured loosely rather than too tightly. In the presence of infection, the skin may be left open for planned delayed primary closure. The flaps should then be left even longer so they can be trimmed at a subsequent operation.

Ray amputation This procedure is performed for the fingers, rather than for the thumb. Ray amputation of border fingers is easier, because there is no ‘hole’ left in the palm that needs to be filled. The skin incision should be marked out on the patient. The standard incision is racquet-shaped with a dorsal longitudinal limb (over the metacarpal for border fingers and between neighbouring metacarpals for central fingers). It is better to keep the skin flaps rather too long, because it is surprising how much skin is required. The dissection starts dorsally (Fig. 7.13). The racquethead incision is then carefully extended and deepened, identifying and preserving the neurovascular bundles. The flexor sheath is opened and the flexor tendons pulled distally while the wrist is flexed. They are then divided and

FIGURE 7.14 Cutting of the flexor tendon, allowing it to retract into the palm.

allowed to retract back into the palm (Fig. 7.14). The interosseous muscles are dissected off the metacarpal via the dorsal incision, preserving their neurovascular supply and minimizing any damage. The intermetacarpal ligaments are divided off the metacarpal bone and can be sutured together later to close the cleft (Fig. 7.15). It is preferred to cut the metacarpal very proximally, just distal to the carpometacarpal (CMC) joint and the insertion of the wrist extensor tendons (Fig. 7.16). Dissecting from proximal to distal, the metacarpal is raised and dissected sharply from the soft tissues to the level of the MCP joint. The attachments of the interosseii are also divided off the proximal phalanx. This leaves a trough where the metacarpal lay (Fig. 7.17) with the neurovascular bundles hanging long volarly. It is preferred to bury the nerve ends deep in the palm to reduce the risk of painful neuromata, although some nerve pain will inevitably result from amputation surgery. Some surgeons will sew the nerve ends together to reproduce one large neuroma.4 We cauterize the vessels and reflect the vessels and nerves into the bed of the interosseous muscles, and suture the nerve to the local muscle to make sure it does not flip out of the muscle bed. The interosseous

Amputation 97

II

IV V

FIGURE 7.17 Trough left in the hand after removal of the metacarpal. III I

FIGURE 7.15 Suturing of the intermetacarpal ligaments to close the cleft.

FIGURE 7.18 The interosseus muscles have been closed with a continuous suture. This is an alternative; we prefer interrupted sutures.

FIGURE 7.16 The metacarpal is cut at the distal end of the metaphysis. This would be suitable for a transposition of the index metacarpal or a suitable level for a ray amputation for a border digit.

muscles are closed over the neurovascular bundles using interrupted or continuous absorbable sutures tied loosely (Fig. 7.18). The skin is closed with interrupted absorbable sutures, typically 5/0 vicryl rapide, with careful contouring of the soft tissues to give a nice line to the side of the hand. The incisions should be placed away from the contact surfaces of the palm (Fig. 7.19). For the central digits, the intermetacarpal space must be closed, otherwise the opening will be cosmetically obvious and allow objects to drop through (see Fig. 7.3).

FIGURE 7.19 Closure of the cleft in the hand.

Some authors advocate simply suturing the intermetacarpal ligaments together, but this rarely closes the gap completely (see Fig. 7.15) and almost always stretches out, leaving a substantial interdigital gap. Immobilization of the whole hand is recommended to protect the repair, which increases


A

B

C

D

E

FIGURE 7.20 A Longitudinal incision for transposition of the border digit metacarpal to close the cleft in a ray amputation or revision of an MCP or PIP joint amputation. B The metacarpals are cut just distal to the CMC joints. C The amputated finger is removed. D Transposition of the border metacarpal. E K-wire fixation of the border metacarpal to the stump of the amputated metacarpal.

Amputation 99 stiffness. It is therefore better and mechanically preferable to transpose the border metacarpal, although this does add to the complexity of the procedure.5 It also allows for some lengthening of the transposed finger, which is particularly valuable for the little finger because its short length relative to the middle finger can be quite obvious following ring finger ray amputation. However, excessive lengthening can cause stiffness by relative tendon shortening. For the transposition, the base of the metacarpal of the border digit is exposed via a longitudinal incision (Fig. 7.20A) and cut just distal to the CMC joint through the metaphysis (Fig. 7.20B). This is best done with an osteotome after pre-drilling the osteotomy sites, but the bone cutting can be done with a saw. The use of osteotome reduces thermal necrosis and enhances bony union. The difficult step is transposing the metacarpal with its muscles into the site of the previous metacarpal (Fig. 7.20C,D). It is made particularly difficult by the bulk of the interosseii. At least one may need to be removed, particularly the radial interosseus of the middle finger or ulnar interosseus of the ring finger. The base of the border digit is placed carefully in line with the metacarpal stump from the amputated digit. This can be held in various ways using K-wires (Fig. 7.20E) or a T-plate. It is very important to check for angular alignment and rotation. This construct can be further secured by a transverse K-wire from the transposed digit to the remaining central digit and double-breasting and suturing the intermetacarpal ligaments with an absorbable suture. The finger position is always checked with an image intensifier. After transposition, we add a plaster of Paris volar splint, replacing it with a full cast after 7–10 days, for a minimum of 4 weeks of immobilization.

OPTIMIZING OUTCOMES Pain relief is the greatest concern after amputation, followed by function. Patients receive oral analgesics such as non-steroidal anti-inflammatory drugs (NSAIDs), unless contraindicated. If there has been a history of dystrophic problems amitriptyline can often be added, starting at

10 mg at night for 4 nights and increasing to 20 mg at night thereafter. If there are major concerns about postoperative pain an indwelling brachial plexus catheter is used and the patient kept in hospital for 3–4 days for bupivacaine injections into the catheter. The patient will be seen again after 3 days to inspect the wound and reinforce the need for elevation, early mobilization and adequate analgesia. If there is concern about adequate pain control, bring the patient into hospital and give them a regional block with an indwelling catheter. Our hand therapy protocol emphasizes gentle rather than aggressive physiotherapy. If there has been a transposition the patients will be seen at 6 weeks for K-wire removal and mobilization out of the plaster. Patients are fitted with wrist splint supports for an additional few weeks. Bony union is confirmed with radiographs at around 12 weeks.

CONCLUSION Amputation is often a treatment of last resort and in some ways a failure of other treatments. It can be viewed rather nihilistically and the operations may be performed poorly. In appropriate circumstances, with appropriate pre-, peri-, and postoperative instructions to the patient and attention to detail, amputation can give very satisfactory results and substantial improvement in hand function. Pain issues must be treated early and aggressively.

REFERENCES 1. Melikyan EY, Beg MS, Woodbridge S, Burke FD. The functional results of ray amputation. Hand Surg 2003; 8: 47–51. 2. Holm A, Zachariae L. Fingertip lesions: An evaluation of conservative treatment versus free skin grafting. Acta Orthop Scand 1974; 45: 382. 3. Louis DS, Palmer AK, Burney RE. Open treatment of digital tip injuries. JAMA 1980; 244: 697–698. 4. Belcher HJ, Pandya AN. Centro-central union for the prevention of neuroma formation after finger amputation. J Hand Surg [Br]. 2000; 25: 154–159. 5. Hanel DP, Lederman ES. Index transposition after resection of the long finger ray. J Hand Surg [Am] 1993; 18: 271–277.

CHAPTER

8

Replantation Techniques Roberto Adani and Riccardo Busa

INTRODUCTION Since the end of the 1960s, the use of microsurgery has revolutionized the treatment of amputation and partial amputation injuries to the upper limb. Upper extremity replantation was first performed by Malt and McKhann at the Massachusetts General Hospital in 1962,1 and the first microsurgical forearm replantation was reported by Chen in 1963.2 In 1968 Komatsu and Tamai3 achieved the first successful microsurgical replantation of a thumb that was completely amputated at the level of the metacarpophalangeal joint. Since these early reports, replantation of severed upper extremities has become an accepted procedure. In the following years, a number of case reports of replantation documented the effectiveness of this procedure for restoring function.4–11 These clinical and experimental studies12–24 made it possible to create precise guidelines for patient selection (indications and contraindications) and the application of particular techniques for unique situations. The microsurgical replantation of a limb remains a procedure of great technical difficulty with high costs. However, the results can be better than those of other reconstructive or prosthetic techniques, provided one rigorously follows these principles: careful selection of the cases to be treated; availability of an expert microsurgical team; a rigorous postoperative and therapeutic clinical protocol; and specialized rehabilitation aftercare. In recent years, services in replantation surgery have been centralized in many countries. A replantation center must have the following: more than three to four experienced microsurgeons who are also trained hand surgeons; trained assistants and nurses; microsurgical facilities; an operating room available 24 hours; and a designated ward for hospitalization of these patients. Research laboratories are necessary for the training of young surgeons, and the rehabilitation center must be inside the hospital.25 The survival of the replanted segment is only the first step towards a satisfactory result

because both surgical and rehabilitation procedures are often necessary.

PATIENT SELECTION AND TYPES OF LESION Given the high cost of replantation procedures, correct selection of cases to be treated is of primary importance. The overall condition of the patient must permit a long surgical procedure (generally >4 hours), which is almost always carried out under general anesthesia and may have considerable intra- and postoperative bleeding problems. An unstable, severely traumatized patient requires their general condition to be stabilized so as to avoid excessive anesthesiologic or surgical risks. The traumatized tissues must be in a suitable condition for replantation. Restoration of sensation is critical to the long-term functional recovery of the replanted segment and is the main advantage of this technique over reconstructive and prosthetic alternatives.25–28 The ‘ideal’ injury is a clean-cut one, but such a condition is rare. The injuries caused by industrial machinery are more common and may have components of crushing, avulsion, degloving, and sometimes burning and contamination of the tissues.

Amputations and partial amputations It is useful to distinguish between complete amputation injuries and those in which some tissue continuity remains (bone, skin, tendons), albeit without vascularization of the distal segment. ‘Replantation’ should be used for complete amputation cases; for ischemic partial amputations, the procedure is ‘revascularization’.29 The continuity of some tissues in partial amputations may facilitate the revascularization procedure. For crushing or degloving injuries, skeletal continuity may impede a

101

102 Hand and Upper Extremity Reconstruction TABLE 8.1 Absolute indications and contraindications to replantation

TABLE 8.2 Relative indications and contraindications to replantation

Absolute indications

Absolute contraindications

Relative indications

Relative contraindications

High surgical risk

Individual demand (for particular functional, cosmetic or social conditions)

Age >70 years

Children (any level of amputation)

Degloving with bone integrity

Associated injuries and systemic diseases

Thumb (any level and type of injury)

High anesthesiologic risk

Multiple digit amputations (more than two amputated fingers)

Technical impossibility of replantation due to local conditions (see text)

Psychiatric disorders

Transmetacarpal amputations

Self-inflicted injuries

Wrist level amputations

Severe tobacco addition

Distal forearm amputations

Alcoholism Drug abuse Multiple level injuries

direct revascularization and require vascular and nerve grafts. In these cases, primary skin closure may be difficult.

Ischemia time Ischemia time is critical for amputation of parts containing muscles. In such cases, the warm ischemia time must be no longer than 6 hours, because of the risk of systemic damage caused by the anaerobic catabolites and oxygen free radicals from muscles getting into the circulation. Optimal preservation of the amputated parts – with or without muscle – at 4ºC permits replantation even after 12 hours of ischemia. For cases presenting beyond 8–10 hours of cold ischemia time, it is recommended to remove the skeletal muscle completely.30 In partial amputations one should not exceed the time limit for warm ischemia of the muscle parts.31

Traumatic mechanisms The traumatic mechanism is of fundamental importance in the technique used for replantation.32 For crush/avulsion injuries, the surgeon can employ vein grafting or vascular transfer from adjacent fingers to bring arterial blood beyond the traumatized area. Obviously, no microsurgical technique can ever replace a vessel if it is completely damaged to its end.

Levels and indications The importance of the thumb in the prehensile function of the hand makes an attempt at replantation virtually always indicated (Tables 8.1 and 8.2; Fig. 8.1). Whatever the level of amputation and the injury mechanism, a replanted thumb offers significant advantages over any other reconstructive or prosthetic technique. The reconstructive techniques that are available today always require substantial morbidity to the donor area, and current prosthetic devices are insensate. An amputation of more than two fingers causes severe impairment to hand function, and in such

cases the indication for digital replantation is absolute. In children replantation (Fig. 8.2), if feasible, must be attempted in order not to limit the child’s learning abilities and psychomotor development. Also, in children, there is greater possibility of sensory restoration and growth of the replanted parts. Transmetacarpal, wrist, and middle-todistal forearm amputations offer satisfactory sensory and motor recovery, making attempts at replantation highly indicated (Fig. 8.3). In the case of amputation of a single finger, the indication is relative when the level of amputation is distal to the insertion of the superficialis flexor tendon33 (Fig. 8.4). Ring avulsion injury has some peculiarity of classification and treatment. Kay’s classification has four categories.34,35 The fourth class includes total cutaneous–subcutaneous avulsion with preservation of skeletal and tendon integrity. In these cases, the use of vascular transpositions or vein grafts may allow replantation with good aesthetic and functional recovery35 (Fig. 8.5; Table 8.2). Replantation of almost completely degloved skin has been successfully reported for the hand and finger. This procedure requires suitable vessels for microanastomoses in the degloved skin flap36,37 (Fig. 8.6). Ishikawa38 classifies digital distal amputations into four levels.38 It is possible to obtain excellent functional and cosmetic results for replantation distal to the distal interphalangeal (DIP) joint if there is at least one arterial repair18,38–44 (Fig. 8.7). If no vessels are available, it is possible to resort to alternative non-microsurgical reconstructive techniques, such as subdermal pocketing and the Hirase technique.45–49

SURGICAL TECHNIQUE Preoperative evaluation and preparation Proper transportation of the amputated part is a critical aspect of successful replantation.50 The part should be

A B

C

D E FIGURE 8.1 A Clean-cut right thumb amputation in a 2-year-old boy. B Amputation at the distal third of the proximal phalanx. C, D Follow-up after 18 months. E X-ray comparing thumbs at follow-up shows no significant alterations in bone growth.


A

C

B

D

FIGURE 8.2 A Right index finger amputation at the level of the proximal phalanx in an 11-month-old boy. B Radiographic pre-operative evaluation showing the level of amputation. C Clinical evaluation at 1 year. D Radiographic evaluation at 1 year.

Replantation Techniques 105

A

C

B

FIGURE 8.3 A Left middle-third clean-cut forearm amputation in a 32-year-old man caused by an industrial cutting machine. B Aesthetic results at 2-year follow-up. C Functional results at 2-year follow-up.


A

B FIGURE 8.4 A Right index finger distal phalanx avulsion lesion in a 25-year-old manual worker. B The amputated segment shows avulsed tendon and neurovascular pedicles. Replantation was not attempted because of local contraindications.

cooled to increase its ischemic tolerance, wrapped in a moist gauze sponge, and placed in a sterile sealed container on ice to provide protection during transportation.23,50 Ischemia time limits for replantation are still a subject of discussion. Successful microreplantation has been reported with cold ischemia times up to 40 hours51–53 and longer.54,55 More proximal amputations permit shorter ischemia times.31 The warm ischemia time should not exceed 6 hours, but this can be prolonged to 10–12 hours by cooling the amputated part.23 During preparation of the patient for surgery, it is essential to inspect the amputated parts accurately with the aid of loupes having 4–6× magnification to debride unusable tissues and to identify arterial and venous vessels that can be used for the anastomoses. It is advisable to place a vascular clip on the available vessels so that they can be found during surgery. The nerves can be tagged with small 6/0 nylon stitches at their ends. This preparatory time is fundamental and common to all amputation levels, especially in cases of multiple digital amputations. The identification of vascular–nervous structures can be facilitated using dorsolateral incisions of 1.5–2 cm, which allow separation of the two cutaneous edges, a dorsal and a palmar one. The palmar edge will include the two vascular–nervous digital pedicles, and the dorsal edge will contain the drainage

veins. The subsequent surgical phases must be carried out using a surgical microscope that should be equipped with double optics, if possible, with a magnification of at least 20× and foot-controlled levers to allow two operating surgeons to work simultaneously.

Preparation of the proximal stump In the operating room, under regional block with bupivacaine or general anesthesia, the severed limb will be debrided of unusable skin edges, devascularized skeletal fragments, and any contaminating materials. The dorsolateral incisions can also be made on the proximal stumps in order to better identify and mark the vascular and nerve structures and to facilitate osteosynthesis. Slight skeletal shortening, which is sometimes inevitable owing to loss of bone substance as a result of the trauma (e.g. an amputation caused by a buzz saw), can in many cases facilitate the subsequent tendon repair, microsutures, and primary skin closure. The arterial and venous anastomoses must not be performed under tension; however, excessive vessel length may cause kinking that can lead to arterial and venous thrombosis. With regard to the digits as well as the thumb, a slight shortening of about 5–8 mm at phalangeal or metacarpal


A B FIGURE 8.5 A Left ring avulsion injury in a 56-year-old woman; level of amputation is the shaft of the middle phalanx distal to the superficialis tendon insertion. B Amputated digit.

diaphyseal level does not generally create problems for the motor function of the digit. At the transmetacarpal level, skeletal shortening must be harmonious for all the metacarpals involved in order not to alter the geometry of the metacarpophalangeal arch of the fingers. The proximal and distal skeletal stumps must be reduced along the correct axes in order to avoid rotation problems that could interfere with the movement of the adjacent healthy fingers. In the case of a degloving injury (Fig. 8.6), the degloved skin should be carefully examined under magnification to identify any suitable vessels (arteries and veins) and nerves for the replantation procedure.36–37

Skeletal fixation The ideal skeletal fixation in a replantation procedure or revascularization will allow skeletal reduction and early mobilization in order to avoid tendon adhesions and joint stiffness. Many methods are available.56–58 We recommend the simplest and fastest technique employing Kirschner wires at digital or metacarpal level (Fig. 8.8) and plates with screws under compression at forearm level. In case of an amputation with severe joint injury, an arthrodesis with a slight shortening and minimal bone resection provides slight digital flexion (20–35º) at the proximal interphalangeal (PIP) joints for functional grip. Even an amputation at the carpometacarpal level can be treated with a primary


C

D

FIGURE 8.5, cont’d C Dissection and harvesting of the long finger ulnar artery. D The ulnar artery of the long finger was anastomosed to the radial artery of the amputated ring finger. The proximal radial digital nerve stump was sutured to the distal digital ulnar nerve. This cross-suture was performed because the distal part of the radial digital nerve was excessively damaged.

joint fusion. An amputation with radiocarpal disarticulation can be treated by wrist arthrodesis using K-wires or plate and screws after minimal bone resection. The thumb trapeziometacarpal, the metacarpophalangeal (MCP) or the interphalangeal joint fusions are well tolerated and do not cause serious impairment to grip, provided they are set in a functional position. Sometimes a less than perfect fusion carried out in an emergency situation will require a secondary fusion procedure. Arthrodesis should never be performed at MCP level in the fingers, as MCP joint immobility severely impedes grip function. It is quite possible to replace damaged MCP joints with silicone or pyrocarbon implants. When implants are used, it is important to perform an accurate primary reconstruction of the capsule and ligaments. For amputations distal to the DIP joint, a single 1 mm K-wire is sufficient, whereas those in Ishikawa zone

II that only involves the soft tissue may not require skeletal fixation because stability is obtained by suturing the nail bed and the soft tissues of the pulp.59

Tendon sutures The technique to be used must be simple and fast in order to shorten ischemia time, and strong enough to allow early mobilization in order to reduce scar adhesions that may require secondary operations. The flexor and extensor tendons are repaired immediately after the skeletal fixation and before the vessels and nerves are sutured. The vessels and nerves are dissected free prior to the tendon repairs. In zone II, we suggest repairing the flexor digitorum profundis only, especially if tendons are not cleanly cut.


E F FIGURE 8.5, cont’d E Dissection and harvesting of dorsal veins ready for transfer. F Two dorsal veins were transferred and anastomosed.

We prefer to use suture techniques that are easy and fast, for example the Kessler, Tajima, or Tsuge techniques using monofilament prolene 3/0 and an epitendinous continuous suture with 6/0 nylon. The extensor tendons can be repaired with resorbable monofilament 4/0 PDS continuous suture.

Arterial anastomoses This must be performed under a high-power (>20×) surgical microscope using microsurgical instruments. A sufficiently long segment of the proximal artery must be freed from the surrounding tissues in order to allow a tension-free repair. It is necessary to remove any intravascular clots and lacerated vessel edges by washing abundantly with heparin solution. The damaged arterial ends will have to be resected using straight micro-scissors until healthy intima is reached.

Once the vessel ends appear healthy, we excise the adventitia and dilate the arterial lumen with 0.2 mm tip dilator forceps, and irrigate the lumen with heparin solution to obtain a strong and pulsatile arterial blood flow. We advise not to proceed with suturing without visible pulsatile bleeding from the proximal artery. The use of a small approximation clamp helps considerably in arterial anastomosis. The tension of the clamp should not be excessive to avoid damaging the delicate vascular walls. After the two arterial ends are correctly matched, we proceed to suturing with 9/0 monofilament nylon using a 100 μm needle for the forearm and wrist level, and 10/0 monofilament with a 100 or 75 μm needle at the metacarpal or digital level. Anastomosis in more distal replantations may require a finer suture and a smaller needle (11/0 or 12/0 and a 50 μm needle). At the forearm and wrist level, we recommend performing both radial and ulnar arterial anastomoses. When the vessels are badly damaged, vein grafts are used.


G

H

FIGURE 8.5, cont’d G Aesthetic results at 3-year follow-up. H Aesthetic results at 3-year follow-up. I Functional results at 3-year follow-up showing residual stiffness of the distal interphalangeal joint.

I


B

A

D C FIGURE 8.6 A Left hand severe degloving injury in a 28-year-old manual worker. B Skin from degloving injury for replantation. C Two dorsal– radial veins were reconstructed by means of vein grafts harvested from the volar aspect of the forearm. D Long-term follow-up.


E

F FIGURE 8.6, cont’d E, F Long-term functional follow-up.

In clean-cut digital injuries, it is generally possible to perform anastomoses in both digital arteries, which gives a greater success rate. Sometimes it is impossible to perform both arterial repairs; in such cases, just one end-to-end arterial anastomosis may be enough. Depending on the injury pattern, we will perform a homodigital cross-shifting technique in which the proximal vessel is anastomosed with the end of the contralateral distal artery. It is of the utmost importance to keep a record, possibly by an illustrative drawing, of the type of anastomoses performed, because secondary operations may be necessary and it is crucial to know the vascular anatomy of the reconstruction. When direct arterial anastomosis is impossible owing to loss of vessels or extended damage, it is necessary to resort to alternative reconstructive procedures such as venous grafting or arterial transfer from an adjacent healthy finger.60–62

Vein grafts at the digital level can be taken from the volar surface of the wrist. Numerous small veins 2–3 mm in diameter run through this area. It is necessary to mark the proximal portion of the vein graft to orient the flow pattern. Such detail is fundamental in avoiding problems. For radial and ulnar artery repair, vein grafts 3–5 mm in diameter can be found more proximally in the forearm. For more proximal arterial repairs, a saphenous vein graft is suitable. To restore the continuity of both digital arteries, it is possible to take a small subcutaneous strip of skin containing two venous segments that can be used for simultaneous bridging. The transposition of a digital artery is a technique that can be useful in complex soft tissue injuries with a large arterial gap. We advise resorting to this technique in ring avulsion lesions and thumb replantations60 (Fig. 8.9). The


A

C

B

D

FIGURE 8.7 A Right long and ring finger amputations at the DIP level in a 42-year-old man. B DIP joint fusion by means of 1 mm Kirschner wires. One artery and one vein were anastomosed for each finger. C, D Results at 1-year follow-up.


A B

C

donating finger must be undamaged so as not to jeopardize its blood flow. The dissection of the donor digital artery must be performed under magnification, while taking special care when ligating or clamping all the collateral branches to avoid damaging the digital nerves. The artery is dissected from the DIP level to the palm. At the palm it is necessary to free the bifurcation point of the common digital artery by ligating the digital artery of the adjacent finger to obtain greater mobilization of the freed artery. To

FIGURE 8.8 A Right transmetacarpal hand amputation in a 26-yearold manual worker. B X-ray of amputated hand. C X-ray of arm showing the level of amputation of the hand.

revascularize the ring finger, it is possible to transpose the ulnar digital artery of the long finger. The thumb can be revascularized in a similar fashion, but it is necessary to create a spacious subcutaneous tunnel to pass the artery from the palm to the thumb. Furthermore, it is always necessary to ligate the radial digital artery of the ring finger, so not to cause a point of excessive traction on the transposed long finger ulnar artery. The use of the radial digital artery of the index finger is not advisable because its caliber


D

E FIGURE 8.8, cont’d D Bone synthesis by means of two simple Kirschner wires for each finger. The ulnar artery and three dorsal veins were anastomosed. E Early follow-up: 2 months post-operatively the patient is undergoing a rehabilitation program.

and length are insufficient. Besides, in amputations of the thumb this vessel can also be damaged at the level of the princeps pollicis artery. For amputations distal to the DIP joint, only one of the two digital arteries is generally reconstructable and, when present, anastomosis of the central pulpar artery, which has a diameter of about 0.3–0.5 mm, is recommended.43,44

Vein repair To replant parts containing skeletal muscle, one should first establish arterial blood flow.13,31 The oxygenated blood will reach the tissues and limit ischemia time to the amputated part, and the venous return will wash out harmful catabolites that have accumulated in the muscles during the anaerobic period. It is generally necessary to abide by the rule that for every reconstructed artery at least two veins must be reconstructed. At digital level, the veins are located in the dorsal subcutaneous layer just underneath the dermal

layer. A thin venous vessel is present on the palmar side of the finger, but the anastomosis is more difficult. At the wrist and forearm level, suitable veins can be located either dorsally, which is more common, or volarly. The digital veins are extremely thin and must be handled carefully under high-power magnification. Endoluminal washing with sterile heparin solution is of great importance. In suturing the very thin veins, we use the so-called ‘immersion’ technique, in which the stitches are applied while the vessel is held immersed in heparinized physiological solution to prevent collapse of the thin venous walls. At wrist and forearm levels 9/0 or 10/0 monofilament nylon sutures can be used, but at hand and fingers level it is always advisable to use 10/0 or 11/0 monofilament sutures. When it is not possible to carry out a sufficient number of direct end-to-end repairs, one can use venous grafts or vein transposition from adjacent healthy fingers.


B

A

D

C FIGURE 8.9 A Left thumb avulsion–amputation in a 30-year-old manual worker. B The level of fracture was at the neck of the proximal phalanx. Tendons were completely avulsed at forearm level and primary reconstruction was not possible. Bone synthesis was performed by means of two Kirschner wires. C A distally bifurcated vein is transferred from the dorsal aspect of the second ray. D The neurovascular ulnar bundle of the long finger is dissected and transferred for anastomosis, preserving the dorsal digital nerve.


E

F

FIGURE 8.9, cont’d E, F Clinical follow-up after 20 months showing stiffness of the interphalangeal joint.

Using a vein graft for vein reconstruction is not simple because of the thin vessel walls and the tendency of the vein graft to collapse. Vein grafts can also be harvested from other non-replantable parts or using the vein transposition technique. The vein transposition procedure is relatively simple and very useful in ring avulsion injuries in which the venous return is insufficient.60 This technique requires a curvilinear incision on the dorsum of the proximal phalanx of the long finger to transpose the vein as far as the DIP joint. It is then transposed to the ring finger under a subcutaneous tunnel (see Fig. 8.5). For the thumb, a venous transfer from the dorsum of the index finger can be performed. If the index finger is damaged, the transfer can be carried out from the long finger, but this requires a longer skin incision and a wider subcutaneous tunnel. In replantation distal to the DIP joint, it is often impossible to locate suitable dorsal veins for repair. It is therefore necessary to look for them in the pulp subdermal layer. If no vein can be found, artificial venous drainage is carried out through controlled bleeding by means of apical incisions and/or leeches (Fig. 8.10). Generally, if the arterial flow is kept patent over a period of 3–5 days, the process of neoangiogenesis creates vascular connections between

FIGURE 8.10 Distal middle finger amputation in a 45-year-old woman; only the central artery was reconstructed. The venous drainage was maintained via leeches at 6-hour intervals for 4 days.

118 Hand and Upper Extremity Reconstruction the distal part and the proximal tissue to promote venous drainage.43,44

Nerve repair The restoration of sensory and motor innervation is fundamental to the success of replantation.63 An insensate hand offers few advantages over a prosthesis, and the absence of vasomotor control sometimes causes considerable intolerance to cold. For this reason nerve repair is very important and must always be performed whenever possible. The nerves are dissected and sutured under microscopic control. The digital nerves are resected with sharp, straightbladed microscissors until healthy axons are seen. The matching of nerve ends is generally made easier by bone shortening. After flexor tendon repair, the flexed posture of the finger facilitates neurorrhaphy. An important rule is to avoid tension in the nerve sutures. At the digital nerve level, three stitches at 120º locations may be enough. At a more proximal level, the fascicles must be matched. The vessels on the perineurium can work as a spatial reference for stitch placement. At more proximal levels, six to eight stitches are required. The continuity of a digital nerve can be restored by grafting a subcutaneous nerve from the forearm.64 Median or ulnar nerve grafting requires the harvesting of sural nerve grafts to make multiple cables to match the fascicles. The various sural nerve segments can be made to stick to each other with fibrin glue to facilitate suturing.

Heterotopic replantation In the case of multidigit amputation, reconstructive priority must be given to the thumb and the ulnar digits: middle/ ring/little. If the amputated thumb is unusable and the index finger is amputated proximally to the proximal interphalangeal joint, it is advisable to replant the index finger to the thumb. Similarly, if the index and long fingers are amputated and the long finger is not replantable, it is preferable to replant the index finger onto the stump of the long finger to improve hand grip.65–67

Finger bank A non-replantable finger can be a donor for venous and arterial vessels and even digital nerves.68 The dorsum of the finger can be the donor of a subcutaneous flap containing dorsal veins. The fingertip can be harvested on one of the digital pedicles as a microsurgical pulp flap to make up for a possible tissue loss in another area. Virtually all digital tissues can be used to make up for losses in other parts, including bone, tendon, skin, and the nail complex.

Skin closure If the amputation is a clean cut, minimal skeletal shortening helps direct skin closure without tension. We apply several 3 mm silicone rubber strips for drainage to avoid the formation of a subcutaneous hematoma.69

The majority of amputations have skin loss, which may be caused by the removal of badly damaged skin. It is a top priority to supply a soft tissue covering, particularly to critical repairs of vessels, nerves, tendons and bone. Local rotation flaps can be used, as well as skin grafts, and rarely, vascularized island or free flaps. ‘Arterializable’ venous flaps can be useful where there is loss of palmar cutaneous tissues to simultaneously restore arterial flow through the veins in the flap and for soft tissue coverage.70

CONCLUSION Emergency upper extremity microsurgical reconstruction after amputation trauma is always a challenging procedure. Accurate patient selection is one of the key points for success in this type of surgery. The indication for replantation is sometimes a difficult decision that should be based on a careful objective and subjective evaluation of the injury and the patient. Such decisions always involve psychological, cultural and social considerations. The patient must be informed that the replantation procedure represents only the first step of treatment with a long rehabilitation program; secondary surgery may be necessary. Patient understanding of the condition and a strong motivation are also essential for a satisfactory long term result.

REFERENCES 1. Malt RA, McKhann CF. Replantation of severed arms. JAMA 1964; 189: 716–722. 2. Chen CW, Chien YC, Pao YS. Salvage of the forearm following complete traumatic amputation. Report of a successful case. Chin Med J 1963; 82: 633–688. 3. Komatsu S, Tamai S. Successful replantation of a completely cutoff thumb: case report. Plast Reconstruct Surg 1968; 42: 374–377. 4. O’Brien BMC, MacLeod AM, Hayhurst JW, et al. Major replantation surgery in the upper limb. Hand 1974; 6: 217–228. 5. Biemer E. Replantation of fingers and limb parts. Technique and results. Chirurgie 1977; 48: 353–359. 6. Morrison WA, O’Brien BM, MacLeod AM. Evaluation of digital replantation-a review of 100 cases. Orthop Clin North Am 1977; 8: 295–308. 7. MacLeod AM, O’Brien BM, Morrison WA. Digital replantation: Clinical experiences. Clin Orthop 1978; 133: 26–34. 8. Tamai S. Digit replantation: analysis of 163 replantations in an 11 year period. Clin Plast Surg 1978; 5: 195. 9. Tamai S, Hori Y, Tatsumi Y, et al. Microvascular anastomosis and its application on the replantation of amputated digits and hands. Clin Orthop 1978; 133: 106–121. 10. Buncke HJ, Alpert BS, Johnson-Giebink R. Digital replantation. Surg Clin North Am 1981; 61: 383–394. 11. Earley MJ, Watson JS. Twenty-four thumb replantations. J Hand Surg 1984; 9B: 98–102. 12. Urbaniak JR, Soucacos PN, Adelaar RS, et al. Experimental evaluation of microsurgical techniques in small artery anastomoses. Orthop Clin North Am 1977; 8: 249–263. 13. Wang S-H, Young K-F, Wei J-N. Replantation of severed limbs. Clinical analysis of 91 cases. J Hand Surg 1981; 6: 311–318. 14. Chen ZW, Meyer VE, Kleinert HE, Beasley RW. Present indications and contraindications for replantation as reflected by long term functional results. Orthop Clin North Am 1981; 12: 849–870. 15. Russel RC, O’Brien BMC, Morrison WA, et al. The late functional results of upper limb revascularization and replantation. J Hand Surg 1984; 9A: 623–633.

Replantation Techniques 119 16. Meyer VE. Hand amputations proximal but close to the wrist joint: prime candidates for reattachment (long term functional results). J Hand Surg 1985; 10A: 989–991. 17. Chen Z, Yu H. Current procedures in China on replantation of severed limbs and digits. Clin Orthop 1987; 215: 15–23. 18. Suzuki K, Matsuda M. Digital replantations distal to the distal interphalangeal joint. J Reconstruct Microsurg 1987; 3: 291–295. 19. Goldner RD, Urbaniak JR. Indications for replantation in the adult upper extremity. Occup Med 1989; 4: 525–538. 20. Feller A-M, Graf P, Biemer E. Replantation surgery. World J Surg 1991; 15: 477–485. 21. Baker GL, Kleinert JM. Digit replantation in infants and young children: determinants of survival. Plast Reconstr Surg 1994; 94: 139–145. 22. Soucacos PN. Indications and selection for digital amputation and replantation. J Hand Surg [Br] 2001; 26: 572–581. 23. Pederson WC. Replantation. Plast Reconstr Surg 2001; 107: 823–841. 24. Allen DM, Levin LS. Digital replantation including postoperative care. Tech Hand Up Extrem Surg 2002; 6: 171–177. 25. Gelberman RH, Urbaniak JR, Bright DS, Levin LS. Digital sensibility following replantation. J Hand Surg 1978; 3: 313–319. 26. Krarup C, Upton J, Creager MA. Nerve regeneration and reinnervation after limb amputation and replantation. clinical and physiological. Muscle Nerve 1990; 13: 291–304. 27. Adani R, Marcoccio I, Castagnetti C, Tarallo L. Long term results of replantation for complete ring avulsion amputations. Ann Plast Surg 2003; 51: 564–568. 28. Unglaub F, Demir E, Von Reim R, et al. Long term functional and subjective results of thumb replantation. Microsurgery 2006; 26: 552–556. 29. Biemer E. Definitions and classifications in replantation surgery. Br J Plast Surg 1980; 33: 164–168. 30. Brunelli G, Vigasio A, Brunelli F. Muscular elementarization in ‘critical’ replantation and revascularizations of the forearm. Ann Chir Main 1985; 4: 337–339. 31. Dell PC, Seaber AV, Urbaniak JR. The effect of systemic acidosis on perfusion of replanted extremities. J Hand Surg 1980; 5: 433–442. 32. Belsky MR, Ruby LK. Double level amputation: should it be replanted? J Reconstruct Microsurg 1986; 2: 159–162. 33. Urbaniak JR, Roth JH, Nunley JA, et al. The results of replantation after amputation of a single finger. J Bone Joint Surg 1985; 67A: 611–619. 34. Kay S, Werntz J, Wolff TJ. Ring avulsion injuries: Classification and prognosis. J Hand Surg 1989; 14A: 204–213. 35. Adani R, Castagnetti C, Busa R, Caroli A. Ring avulsion injuries: microsurgical management. J Reconstruct Microsurg 1996; 12: 189–194. 36. Adani R, Busa R, Castagnetti C, et al. Replantation of degloved skin of the hand. Plast Reconstruct Surg 1998; 101: 1544–1551. 37. Adani R, Busa R, Tarallo L, Castagnetti C. Update on replantation of degloved skin of the hand. Plast Reconstruct Surg 2004; 114: 1228–332. 38. Ishikawa K, Ogawa Y, Soeda H, Yoshida Y. A new classification of the amputation level for the distal part of the finger. J Jpn SRM 1990; 3: 54–62. 39. Goldner RD, Stevanovich MV, Nunley JA, Urbaniak JR. digital replantation at the level of the distal interphalangeal joint and the distal phalanx. J Hand Surg 1989; 14A: 214–220. 40. Foucher G, Norris RW. Distal and very distal digital replantations. Br J Plast Surg 1992; 45: 199–203. 41. Yamano Y. Replantation of fingertips. J Hand Surg 1993; 18B: 157–162. 42. Kim W-K, Lim J-H, Han S-K. Fingertip replantations: clinical evaluation of 135 digits. Plast Reconstruct Surg 1996; 98: 470–476. 43. Akyurek M, Safak T, Kecik A. Fingertip replantation at or distal to the nail base: use of the technique of artery-only anastomosis. Ann Plast Surg. 2001; 46: 605–612. 44. Matsuzaki H, Yoshizu T, Maki Y,Tsubokawa N. Functional and cosmetic results of fingertip replantation: anastomosing only the digital artery. Ann Plast Surg 2004; 53: 353–359.

45. Kim KS, Eo SR, Kim DY, et al. A new strategy of fingertip reattachment: sequential use of microsurgical technique and pocketing of composite graft. Plast Reconstruct Surg 2001; 107: 73–79. 46. Adani R, Marcoccio I, Tarallo L. Treatment of fingertips amputation using the Hirase technique. Hand Surg 2003; 8: 257–264. 47. Heistein JB, Cook PA. Factors affecting composite graft survival in digital tip amputations. Ann Plast Surg 2003; 50: 299–303. 48. Lin TS, Jeng SF, Chiang YC. Fingertip replantation using the subdermal pocket procedure. Plast Reconstruct Surg 2004; 113: 247–253. 49. Uysal AI, Kankaya Y, Ulusoy MG, et al. An alternative technique for microsurgically unreplantable fingertip amputations. Ann Plast Surg 2006; 57: 545–551. 50. Weiland AJ, Raskin KB. Philosophy of replantation 1976–1990. Microsurgery 1990; 11: 223–228. 51. Chiu H-Y, Chen M-T. Revascularization of digits after thirty-three hours of warm ischemia time: a case report. J Hand Surg 1984; 9A: 63–67. 52. Inoue G, Nakamura R, Inamura T. Revascularization of digits after prolonged warm ischemia J Reconstruct Microsurg 1988; 4: 131–135. 53. Baek S-M, Kim S-S. Successful digital replantation after 42 hours of warm ischemia. J Reconstruct Microsurg 1992; 8: 455–458. 54. Wei F-C, Chang Y-L, Chen H-C, Chuang C-C. Three successful digital replantations in a patient after 84, 86 and 94 hours of cold ischemia time. Plast Reconstruct Surg 1988; 82: 346–350. 55. Iglesias M, Serrano A. Replantation of amputated segments after prolonged ischemia. Plast Reconstruct Surg 1990; 85: 425–429. 56. Whitney TM, Lineaweaver WC, Buncke HJ, Nugent K. Clinical results of bony fixation methods in digital replantation. J Hand Surg 1990; 15A: 328–334. 57. Brown ML, Wood MB. Techniques of bone fixation in replantation surgery. Microsurgery 1990; 11: 255–260. 58. Chew WY, Chong AK. Intra-articular loop wire fixation allows joint preservation and early motion in replantation around the proximal interphalangeal joint. Hand Surg 2005; 10: 187–191. 59. Sabapathy SR, Venkatramani H, Bharathi RR, Sebastin SJ. Distal fingertip replantation without skeletal fixation. J Reconstruct Microsurg 2005; 21: 11–13. 60. Adani R, Castagnetti C, Busa R, Caroli A. Transfer of vessels in the management of thumb and ring avulsion injuries. Ann Acad Med 1995; 24: 51–57. 61. Akyurek M, Safak T, Kecik A. 1: Ring avulsion replantation by extended debridement of the avulsed digital artery and interposition with long venous grafts. Ann Plast Surg 2002; 48: 574–581. 62. Sukop A, Tvrdek M, Kufa R. The primary use of venous grafts in thumb replantation. Acta Chir Plast 2005; 47: 103–106. 63. Murakami T, Ikuta Y, Tsuge K. Relationship between the number of digital nerves sutured and sensory recovery in replanted fingers. J Reconstruct Microsurg 1985; 1: 283–286. 64. Nunley JA, Ugino MR, Goldner RD, et al. Use of the anterior branch of the medial antebrachial cutaneous nerve as a graft for the repair of defects of the digital nerve. J Bone Joint Surg 1989; 71A: 563–567. 65. Soucacos PN, Beris AE, Malizos KN, et al. Transpositional microsurgery in multiple digital amputations. Microsurgery 1994; 15: 469–473. 66. Schwabegger AH, Harpf C, Rumer A, et al. Transpositional replantation of digits. Case reports. Scand J Plast Reconstruct Surg Hand Surg 1999; 33: 243–249. 67. Elliot D, Henley M, Sammut D. Selective replantation with ulnar translocation in multidigital amputations. Br J Plast Surg 1994; 47: 318–323. 68. Schoofs M, Raoult S, Fevrier P, et al. Strategie du doigt banque. Ann Chir Main Memb Super 1994; 13: 240–246. 69. Meyer VE. Wound closure and decompression in the upper limb replantation. Ann Chir Main Memb Super 1988; 9: 129–134. 70. Nishi G, Shibata Y, Kumabe Y, et al. Arterialized venous skin flaps for the injured finger. J Reconstruct Microsurg 1989; 5: 357–365.

CHAPTER

Wrist Arthroscopy and TFCC Repair

9

Scott F. M. Duncan and Kevin J. Renfree

INTRODUCTION The indications for diagnostic and therapeutic use of wrist arthroscopy continue to expand, as it offers many advantages over open procedures for numerous types of condition. Currently it is used for diagnostic evaluation, loose body removal, debridement, triangular fibrocartilage complex (TFCC) repair, distal ulnar resection (‘wafer’ procedure), evaluation of carpal instability, treatment of distal radius and scaphoid fractures, dorsal ganglion resection, evaluation of Kienbock’s disease, treatment of septic wrist, synovectomy for inflammatory arthritis and biopsy, as well as radial styloidectomy and proximal row carpectomy.1–8 The ulnar side of the wrist has sometimes been described as the ‘black box’ of the wrist. The anatomy is relatively complex, with overlying areas of potential pathology, and can provide challenges in diagnosis and surgical access (Figs 9.1 and 9.2). Ulnar-sided wrist pain can be a manifestation of acute or chronic disorders of the TFCC, extensor carpi ulnaris tendon along with its subsheath, ulnocarpal ligament, distal radioulnar joint, triquetrum, lunate, pisotriquetral joint, flexor carpi ulnaris, and/or dorsal ligaments of the wrist (Table 9.1).9–11 This chapter focuses on wrist arthroscopy and TFCC repairs. The TFCC is a cartilaginous and ligamentous structure that is a composite of several structures.12 The central articular disc is bordered by ligaments. The disc is made up of interwoven collagen fiber sheets with obliquely oriented fibers, which can withstand multidirectional stresses. The disc attaches to the radius as well as to the ulnar styloid. The dorsal and volar radioulnar ligaments, located along the dorsal and volar aspects of the articular disc, are thick and fibrous.13 They function to stabilize the distal radioulnar joint. The ulnocarpal ligament complex, located along the dorsal and volar aspects of the articular disc, consists of the ulnolunate and ulnotriquetral ligaments. These are considered extrinsic ligaments and help support the ulnar carpus. Dorsally, the TFCC is bordered by the extensor carpi ulnaris and its subsheath, which also stabilizes the ulnar carpus. On cross-section the articular disc is bicon-

cave: thinner in the center and thicker at its margins. It functions to transfer loads from the wrist bones to the ulna. The vascular supply to the TFCC arises from three arteries: the ulnar artery, and the palmar and dorsal branches of the anterior interosseous artery.14 Two branches from the ulnar artery (the palmar radiocarpal and dorsal radiocarpal) send vessels in a radial fan-shaped pattern to the peripheral portion of the TFCC. This supplies the volar and ulnar aspects of the TFCC. The palmar branch of the anterior interosseous artery provides blood flow to the palmar distal radioulnar joint ligament and supplies a portion of the blood to the volar aspect of the TFCC. The dorsal branch of the anterior interosseous artery gives out several small branches that supply the dorsal distal radioulnar joint ligaments and the dorsal peripheral portion of the TFCC. Histologic sections have shown that the penetration only occurs in the peripheral 10–40%, with the central section and radial sections remaining avascular. This has important implications with respect to healing potential and results of repairs. Neural innervation of the TFCC is confined to the periphery of the disc, and arises from the ulnar nerve and branches of the posterior interosseous nerve.15 Based on previous studies, it has been assumed that an injury in this portion of the TFCC could stimulate nerves that may elicit painful symptoms. Biomechanical tests by Palmer and Werner, as well as others, have shown that in ulnar neutral variance 60–80% of the load is borne by the radius and 20–40% by the ulna.16–18 With the TFCC removed, the radius transmits 90% of the load and the ulna only 5%. The TFCC was also noted to be an important stabilizer of the distal radioulnar joint, both in dorsal and palmar directions. Excision of the central one-third of the articular disc does not appear to significantly change the distribution of forces between the radius and ulna.17 The amount of load transmission also depends on the rotational position of the forearm.19 With supination, the radius is relatively distal on the ulna, and

121

122 Hand and Upper Extremity Reconstruction Lunate fossa

Dorsal radiocarpal ligament Triangular articular disc Dorsal distal radioulnar ligament

Scaphoid fossa

ECU tendon

Capsule

Prestyloid recess

Ulnotriquetral ligament

Radioscaphocapitate ligament

Palmar distal radioulnar ligament Ulnocapitate ligament

Short radiolunate ligament

Long radiolunate ligament

Ulnolunate ligament

FIGURE 9.1 Axial anatomy.

Intercarpal ligaments Long radiolunate ligament

Ulnotriquetral ligament Pisiform

Scaphoid

Radioscaphocapitate ligament

Triquetrum Lunate

Ulnar capsule Scaphoid fossa

Ulnolunate ligament Meniscus homologue Prestyloid recess Triangular articular disc Ligamentum subcruentum

Lunate fossa Short radiolunate ligament

Radius

FIGURE 9.2 Coronal anatomy.

Superficial portion of dorsal DRUL Deep portion of dorsal DRUL

Ulna

Wrist Arthroscopy and TFCC Repair 123

OPERATIVE CONSIDERATIONS TABLE 9.1 Differential diagnosis of ulnar-sided wrist pain TFCC tears ECU subluxation Lunotriquetral ligament injury and instability Pisotriquetral arthritis Chondral lesions of the ulnocarpal or midcarpal joints Ulnar artery thrombosis Ulnar neuropathy

this creates an ulnar negative variance (less load on ulna). Conversely, in pronation, the radius is relatively proximal compared to the ulna, resulting in a relative ulnar positive variance (more load on the ulna). As the forearm rotates, the dorsal and volar radioulnar ligamentous portions of the TFCC tighten, which affects the stabilizing force on the head of the ulna. Thus, the TFCC appears to have two functions, first to transmit load and second to stabilize the distal radioulnar joint. Based on these biomechanical considerations, injuries could be caused by a direct compressive load from the ulnar carpus to tear the disc.15,20 The other would be a chronic injury that repeatedly grinds or compresses the TFCC, such as a gripping pronation maneuver or ulnar positive variance (congenital or acquired).

Summary Box: Indications and contraindications Indications for traumatic TFCC repair ● TFCC tears that have an ulnar neutral/ulnar negative variance are amenable to repair ● TFCC injuries with ulnar-sided wrist symptoms that are significant enough to prevent the patient from engaging in their usual activities ● Failure of non-operative interventions, such as antiinflammatory medication, rest, and immobilization ● Ulnar-positive variant patients with traumatic tears require shortening of the ulna in addition to repair Treatment summary ● Type IA lesions – debride ● Type IB lesions – repair ● Type IC lesions – repair plus ligament capsulodesis or repair ● Type ID lesions – repair if possible, otherwise debride Treatment summary – degenerative TFCC lesions Type IIA – ulnar shortening osteotomy ● Type IIB – ulnar shortening osteotomy ● Type IIC – debride and also perform arthroscopic wafer or ulnar shortening ● Type IID – debridement with arthroscopic wafer or ulnar shortening if the lunotriquetral ligament is unstable ● Type IIE – ulnar shortening with debridement and pinning of the lunotriquetral ligament if unstable despite shortening of the ulna ●

Operative intervention for acute TFCC injuries can be considered after a trial of immobilization. DRUJ instability, as well as ECU subluxation, should be ruled out when possible. If X-rays are negative without evidence of instability on clinical examination, 4 weeks of immobilization in a long arm or Muenster cast with the forearm in mid-supination is reasonable.9,21 With a subacute injury, a cortisone injection may reduce synovitis and ECU tendinitis, resulting in symptomatic improvement. Central tears of the disc can become asymptomatic despite not healing. TFCC tears that are associated with ulnar positive variance may worsen over time.22,23 One study has suggested a correlation between age and TFCC perforations;24 however, these have been identified even in fetal cadavers. Therefore, central TFCC tears can be found incidentally, and may not be the cause of a patient’s symptoms.

PATIENT HISTORY The patient may describe a specific injury, such as a fall on an outstretched hand. This applies an extension–pronation force on an axially loaded wrist, resulting in TFCC injury. Forced rotation, such as when a drill binds and rotates the wrist instead of the drill bit, and distraction forces to the volar forearm and wrist, have also been noted to result in TFCC tears. However, the most common source of TFCC tears is probably distal radius fractures. It is difficult to isolate TFCC injuries from other problems on the ulnar side of the wrist based solely on history and physical examination. Repetitive pronation and ulnar deviation in a patient with ulnar positive variance can result in TFCC compromise. Gripping and twisting activities (twisting of a jar lid or screwdriver), as well as activities that result in ulnar deviation of the wrist (pushing oneself up from a seated position on an arm rest) can localize pain to the ulnar aspect of the wrist. Mechanical symptoms such as clicking or popping during activities may also be noted. Patients may present with reduced forearm rotation or wrist motion secondary to a TFCC tear. The physical examination often localizes tenderness over the volar–ulnar aspect (‘foveal’ region) of the wrist; however, gross inspection typically shows no significant swelling, erythema, ecchymosis, or other signs of injury unless there is an underlying fracture. Neurovascular examination and range of motion are usually normal, unless there is distal radioulnar joint instability resulting in a decrease in pronation/supination motion. A ‘TFCC compression test’ can be performed by axially loading while simultaneously rotating an ulnar-deviated wrist. This provocative test is positive when it results in pain, with or without a click. One should compare the findings to those on the contralateral side. Direct pressure over the dorsal aspect of the TFCC at the ulnocarpal joint may also cause pain in patients who have TFCC trauma. A ‘lunotriquetral ballottement test’ can be useful in trying to assess any instability between the lunate and triquetrum that may be contributing to the ulnar-sided wrist

124 Hand and Upper Extremity Reconstruction pain.25 This is performed by holding the triquetrum in one hand and the lunate in the other; the motion between the two bones is ascertained and compared with the contralateral side. Increased motion, especially if painful, can indicate lunotriquetral instability. Point tenderness over the lunotriquetral interval or ulnar snuffbox can also be an indication of lunotriquetral instability. Distal radioulnar joint stability should be assessed with a ‘piano key’ maneuver. This is performed by stabilizing the radius and applying pressure to the ulna. Increased prominence or motion of the ulna relative to the radius is a sign of potential instability and is compared to the contralateral side. The test is usually performed with the forearm in supination, neutral, and pronation. If there is gross laxity of the ulna, this usually represents severe disruption and tearing of the triangular fibrocartilage complex. This type of significant instability usually cannot be treated by arthroscopic methods alone; however, mild to moderate instability can usually be treated with arthroscopic repair. The ulnar aspect of the carpus should also be checked for any evidence of sag, which may represent a type IB or IC tear. Concomitant ECU tendinitis is not uncommon. The ECU tendon should be checked for subluxation with combined active ulnar deviation of the wrist and forearm rotation. A Jamar dynamometer may demonstrate weakened grip strength curves relative to the opposite side. TFCC injuries can also be part of a larger problem involving the wrist, and any ulnocarpal clicks, pops, and grinds that the patient may describe can represent several different simultaneously occurring pathologies. Diagnostic injection(s) of local anesthetic can help localize the pathology. Advanced imaging studies or arthroscopy may also be helpful.

DIAGNOSTIC IMAGING Plain radiographs should include views with posteroanterior (PA) and lateral images with the shoulder in 90º abduction (Fig. 9.3), elbow flexed 90º, and the forearm in neutral rotation (‘ulnar variance views’).26 These are used to evaluate carpal alignment, ulnar variance, the distal radioulnar joint, and ulnar styloid anatomy. Cystic lesions can sometimes be seen on the ulnar aspect of the lunate in chronic abutment in patients with ulnar positive variance.27 This should not be confused with Kienbock’s disease. Clenchedfist views with ulnar deviation and pronation may accentuate ulnar positive variance not seen on the neutral static images.19,28 More advanced imaging studies include wrist arthrography, CT scans, triple-phase bone scans, MRI, and MRI arthrography. Normally there is no communication between the distal radioulnar joint, radiocarpal joint, and midcarpal joints. A triple injection arthrogram involves placing dye into each of these previously mentioned joints and watching for any flow of dye from one compartment to the other.29–31 Tears of the lunotriquetral ligament and scapholunate ligaments are easily evaluated with this technique; however, the extrinsic capsular ligaments are not visualized. Unfortunately, there is a very high rate of false positive

FIGURE 9.3 Pronated view with 90º of shoulder abduction.

studies, with 74% of patients who have a positive arthrogram on the symptomatic side also having a positive examination on the asymptomatic side.32 This rate probably increases with age as a result of degenerative asymptomatic perforations in these structures.33 Triple-phase bone scans may be useful in identifying inflammation of the wrist, but probably have limited value. The bone scan may be helpful where there is an occult fracture or ulnar impaction with bone changes. The utility of CT scan is mainly for carpal instability and checking for DRUJ subluxation or joint incongruity, particularly after a distal radius fracture.34 For instability, fine cuts (1 mm) through the DRUJ in supination, pronation, and neutral positions are done, comparing to the opposite side. MRI is currently a highly utilized imaging study for TFCC and other potential ulnar-sided pathology.35 Potter et al.35 showed that MRI had a diagnostic sensitivity of 100% and accuracy of 97% for TFCC tears. A dedicated wrist coil should be used whenever possible to improve accuracy, especially for diagnosis of LT ligament tears. The T2-weighted image in the coronal plane is usually the most helpful view for the latter. MRI may show marrow changes in the lunate, allowing the surgeon to differentiate Kienbock’s disease (diffuse changes) from ulnar impaction syndrome (localized to the proximal–ulnar aspect). A combination of arthrography and MRI is probably the most accurate. Contrast material (gadolinium) is injected into the radiocarpal joint under fluoroscopic guidance and then the patient is placed into the MRI scanner with the wrist coil. These images provide superior contrast and show leakage between torn ligaments or torn TFCC, while still allowing evaluation of the extrinsic ligaments. The key with any study is that the pathology must correlate with the symptoms, history, and physical examination.36 A commonly used classification of TFCC injuries has been proposed by Palmer.21 His system is defined by the type and location of the lesion, two main factors affecting treatment. The two basic categories are type I (traumatic


FIGURE 9.4 Type IA tear: isolated central disk tear.

tears), and type II (degenerative tears). A class IA tear of the TFCC is an isolated central disc tear (Fig. 9.4). It is usually several millimeters away from the radial attachment and is usually in a volar to dorsal direction that can result in a flap. Type IB tears represent a peripheral tear from the insertion on the distal ulna (Fig. 9.5). This can happen with a fracture or fracture of the ulnar styloid. Because the peripheral region of the TFCC is continuous with the floor of the ECU subsheath, a type IB injury may be associated with disruption of the ECU tendon sheath. Clinically, this can be demonstrated by subluxation of the ECU tendon. Occasionally instability of the DRUJ is also found with type IB tears. A type IC tear is from the lunate or triquetrum through the ulnocarpal ligaments (Fig. 9.6). Disruption of these volar ulnocarpal extrinsic ligaments can result in a supination deformity of the carpus on the ulna, otherwise known as a ‘sag’ sign. Finally, Palmer type ID tears are traumatic avulsions of the TFCC from its radial insertion (Fig. 9.7). These tears are usually oriented in a volar to dorsal direction and are located within 1–2 mm of the sigmoid notch; they are frequently seen with distal radius fractures. Type II tears describe degenerative changes to the TFCC. The classification is based on the natural progression of these degenerative changes. In type IIA there is wearing of the TFCC without perforation or chondromalacia, and this represents the earliest stage of degeneration. Type IIB lesions have wearing or fraying of the TFCC with some chondromalacia of the lunate, and/or ulna, and/or

FIGURE 9.5 Type IB tear: peripheral tear from insertion on distal ulna.

FIGURE 9.6 Type IC tear: disruption of volar ulnocarpal extrinsic ligaments.


FIGURE 9.7 Type ID tear: avulsion of TFCC from its radial insertion.

FIGURE 9.8 Type IIC tear: perforation of the TFCC.

triquetrum. Again, there is no perforation of the cartilaginous disc. Type IIC tears (Fig. 9.8) have a perforation of the TFCC that is usually centrally located, and this is combined with lunate chondromalacia. Again, this represents a natural progression of this degenerative process. Type IID perforations have lunate and/or ulnar chondromalacia and lunotriquetral ligament perforation. Carpal instability patterns such as VISI (volar intercalated segment instability) are not seen. The final stage is type IIE, where there is degenerative arthritis of the ulnocarpal joint and distal radioulnar joint, as well as perforation of the TFCC. There are usually lunotriquetral tears, and VISI may be seen in this later-stage process.

tion is carried out down to the capsule. A curved mosquito is then used to gently enter the joint. Trocar and cannula are then placed in the joint. A diagnostic arthroscopy is performed, first on the radial side of the wrist looking at the radial styloid, prestyloid recess, checking the scapholunate ligament, and lunotriquetral ligaments. An ulnar portal is then created by again incising the skin. The author’s preference is a 6R portal. A probe is then inserted and the structures examined with its assistance. The probe is used to examine the TFCC tear as well. A full radius motorized shaver is then inserted: a 2–3 millimeter size is usually adequate. The tourniquet is inflated if significant bleeding is found. The shaver is used to remove any synovitis tissue and to debride the central tear. Radiofrequency probes are commonly used in our practice, and these can quickly remove some of this firm, fibrous, and cartilaginous tissue. It is important to also examine the midcarpal joint. This can be done prior to TFCC debridement or at the end of the ulnocarpal procedure. Once the synovitis has been debrided, the probe can be very useful to assess tear stability, tension of the TFCC (‘trampoline test;’ Fig. 9.11), ligamentous integrity, and to look for any evidence of ulnotriquetral ligament tears. Occasionally the surgeon may need to switch the viewing and working portals in order to make sure the debrided TFCC area is nice and smooth. Again, it is important to excise only the unstable or frayed portion; the peripheral attachments need to be left alone.37 Portal sites are usually closed with 4/0 or 5/0 nylon. Postoperative therapy is performed as described earlier. Over 80% of patients require

TECHNICAL CONSIDERATIONS Arthroscopic treatment of type IA tears is an outpatient procedure under regional or general anesthesia. A wellpadded tourniquet is placed just above the elbow. The wrist is examined under anesthesia for any evidence of mechanical symptoms, particularly for DRUJ instability. The upper arm is then secured to the table with a Velcro strap and prepared and draped. The arm is then placed in a traction tower with nylon or plastic finger traps. If the finger traps cannot hold adequately, or if the skin is quite fragile, Coban is then used to protect the skin or enhance the girth of the fingers. Twelve pounds of traction is usually placed across the wrist joint. A number 15 blade is used to make a small, superficial incision where the 3/4 portal will be placed. Blunt dissec-


FIGURE 9.9 Wafer procedure; burring of the ulnar head.

FIGURE 9.10 Wafer fluoroscopic image.

no further intervention and have a good or excellent result.38–41

confirm reapproximation of the TFCC and restoration of the ‘trampoline’ effect.44,45 In cases of DRUJ instability the author will consider pinning the radius and ulna with two 0.062 K-wires and utilizing a Munster cast for 6 weeks. If the DRUJ was stable prior to TFCC repair, then usually immobilization in a Munster cast for 6 weeks is adequate. In patients who have had treatment that has been delayed for over 6 months, we consider performing ulnar shortening with our repairs.46 After the 6 weeks of immobilization, a therapy program is started and any K-wires are removed to allow aggressive forearm and wrist range of motion.

TYPE IB LESIONS Type IB lesions can occur in association with or without a fracture of the ulnar styloid. If there is a fracture of the styloid, fixation of this fracture is the preferred method of treatment when possible. The distal radioulnar joint should be tested for stability. If it is unstable but the styloid fracture is relatively non-displaced, then long-arm immobilization in neutral forearm rotation is treatment. Casting is usually needed for up to 6 weeks. If the fractured ulnar styloid is displaced and the distal radioulnar joint unstable, then open reduction and internal fixation is recommended. The arthroscopy setup is similar to what was described for type IA tears. The author’s preference is to try and repair these lesions when and if at all possible (Fig. 9.12A,B,C). Debridement of type IB lesions is reserved for those that are, for some reason, irreparable. The author’s preference is to use a technique similar to that described by Trumble et al.6 After completion of the diagnostic arthroscopy, the scope is placed in the 6R portal and the cannula in the 3/4 portal. A 2/0 PDS meniscal repair type suture is used, with a double-armed suture. The needle is then passed through the cannula and directed towards the TFCC tear. The needle exits through the ulnar wrist capsule and skin along the ulnar border of the wrist; a second needle is placed in a similar fashion, and this also exits through the ulnar border of the wrist,42 leaving a horizontal mattress suture for repair. Usually two sutures are sufficient. An incision is made between the extensor carpi ulnaris and flexor carpi ulnaris tendons, adjacent to the ulnar head. Care is taken to dissect out the soft tissue structures, particularly the dorsal ulnar sensory branch.43 Once the soft tissues have been cleared, the sutures are tied over the ulnar capsule. Arthroscopic reinspection should

TYPE IC LESIONS Type IC lesion tears involve the volar aspect of the articular disc and represent an avulsion of the disc from the ulnar extrinsic ligament complex (ulnolunate and ulnotriquetral ligaments). In these cases the patient’s examination may show a carpal supination (‘sag’) deformity. Diagnostic studies may not be helpful. Arthrography can be falsely positive as a result of a normal communication between the radiocarpal and pisotriquetral joints. At the time of arthroscopy, excessively lax ulnar extrinsic ligaments are noted, as well as wide visualization of the pisotriquetral joint through the 6R portal. Osterman47 has described a technique for repairing smaller tears arthroscopically. A similar approach and technique is used as when repairing type IB lesions. For larger tears, an open procedure is recommended.48 Because of the location of these volar tears, care is taken to avoid injuring the ulnar artery or nerve. As described in the previous section, needles with 2/0 PDS suture are passed through the tear (capsular area) where the defect lies, and this helps close and tighten the ulnar extrinsic ligaments and repair the tear.49 A technical point to consider is also to reef some of the dorsoulnar portion of the TFCC so that it helps ‘tighten’ the ulnocarpal ligaments.

128 Hand and Upper Extremity Reconstruction For large defects that are not amenable to arthroscopic repair, an open repair is performed. The author favors the volar approach as this permits direct shortening of the ulnar extrinsic ligaments. The repair is usually augmented with a segment of flexor carpi ulnaris tendon. This is a strip of the tendon that is based distally and brought through in a dorsal direction. Cooney9 has described performing an osteotomy as well, but we have no experience with this approach.

TYPE ID LESIONS Type ID lesions represent avulsion of the TFCC from its normal attachment on the radius and sigmoid notch. Repairing these can be challenging, and in many cases debridement is acceptable. Cooney et al.48 have reported excellent results in treating these injuries by open repair. Trumble et al., Jantea et al., Segerman, and Short have also described repair techniques.6,49–51 The authors prefer the technique described by Short.51 The arthroscope is placed in the 3/4 portal and a 6U portal is developed. Using the 6U portal, motorized burs are brought in and the ulnar aspect of the radius is debrided to bleeding bone. A 0.062 K-wire is then introduced and directed towards the debrided area of the sigmoid notch. Multiple drill holes are then made through the bone, traversing across the radius and exiting between the first and second dorsal compartments. Usually four holes are required. The 2/0 PDS meniscal repair kit sutures are used. This double-armed suture has the first needle placed through the cannula and passes through the TFCC approximately 3 mm from its free edge. The needle is then passed through one of the drill holes on the radius and pulled through the skin. The second needle is then passed through the cannula and TFCC in a similar fashion, and then passes down a different drill hole. These steps are usually repeated once more so that a total of two sutures is used to repair the TFCC. Once these have been passed, a small incision is made between the first and second dorsal compartments. Blunt dissection is carried down to bone. The sutures are then collected and tied over cortical bone, reducing the TFCC against the sigmoid notch. The radius and ulna are pinned together in neutral rotation with two 0.062in K-wires. Patients are placed in a Munster cast for 6 weeks. In patients whose treatment was delayed more than 6 months, Trumble has noted an improvement in outcome if ulnar shortening is also performed.46 Unfortunately, there is a lack of long-term studies comparing TFCC debridement to repair of type ID lesions. If repair fails, one may then consider debridement for these injuries.52

impaction syndrome can be congenital, idiopathic, or sequelae of trauma such as radial shortening after fracture. Other potential causes of secondary ulnar impaction include distal radial growth arrest after an epiphyseal fracture or proximal migration of the radius due to a radial head resection after Essex–Lopresti injury. Dynamic ulnar impaction has been described, and this occurs with activities such as forceful rotation or excessive gripping that loads the ulnocarpal joint. Wrist arthroscopy can be helpful in the treatment of primary ulnar impaction. Secondary ulnar impaction, however, usually requires other reconstructive measures. Palmer’s classification system rates these progressive degenerative changes into five subtypes, mentioned earlier.21 On examination the TFCC compression (foveal tenderness) test is usually positive. Pain with forced ulnar deviation (impaction sign) is frequently positive. This maneuver should be performed in neutral pronation and supination. A ‘shuck’ test should also be performed for lunotriquetral instability. Compressing the DRUJ may also elicit symptoms if arthritic changes have occurred.53 Another test that can be helpful in evaluation is measurement of grip strength in both pronation and supination. If arthroscopy is carried out it is important to visualize the midcarpal joint for thorough evaluation of the lunotriquetral ligament. In some cases, chondromalacia of the hamate may also be discovered as a cause of ulnar-sided wrist pain in a patient with a bifacet lunate. Chondroplasty of the hamate can then be performed. In general, treatment is designed to decompress the ulnar carpus and head. An advantage of the wafer procedure is that, if done correctly, it does not disturb the DRUJ.54 For symptomatic distal radioulnar joint arthritis, hemiresection, tendon interposition, Sauve–Kapandji, modified Darrach resection, or ulnar head implant may be considered.53 Treatment of type IIA and IIB tears is usually by arthroscopy and open ulnar shortening.55 See Figures 9.12, 9.13 and 9.14 for arthroscopic

TYPE II DEGENERATIVE TFCC LESIONS Type II degenerative TFCC lesions are frequently thought of as ulnocarpal impaction syndrome. Some patients may be asymptomatic. Symptomatic degenerative tears are usually the result of chronic overloading of the ulnocarpal joint. In addition to the TFCC tear, there can also be changes involving the ulna and carpus. Causes for ulnar

FIGURE 9.11 Normal trampoline test.


A

A

B

B

C

C

FIGURE 9.12 A Case 1: Degenerative tear with ulnocarpal abutment. B After central debridement of the TFCC with RF ablation. C Unstable LT joint as seen from the midcarpal portal.

FIGURE 9.13 A Case 2: Radiofrequency ablation of the TFCC with a central tear. B After debridement of the TFCC down to a stable rim. C Normal midcarpal LT joint view with probe.

130 Hand and Upper Extremity Reconstruction views of before and after treatment pictures, as well as views of normal and torn lunotriquetral ligaments. Treatment of type IIC tears depends on ulnar variance. If non-operative intervention does not alleviate the patient’s symptoms adequately, arthroscopic debridement of the TFCC tear, as well as a potential wafer procedure or ulnar shortening, is done to address ulnar positive variance. The wafer procedure, as described by Felden et al.,56 was initially performed through an open procedure. This has subsequently been modified to be performed arthroscopically.55,57 For this diagnosis we look specifically at the articular surfaces of the lunate and triquetrum and carefully probe the lunotriquetral ligament. Synovectomy is frequently required to remove some of the inflammatory tissue so that these structures can be better visualized. Through the hole in the TFCC, the ulnar head can be examined and the articular surface seen by moving the forearm in pronation and supination. If there is instability of the lunotriquetral joint, either with a diastasis or a frank tear, a wafer procedure is not recommended.54 In this circumstance, an open ulnar shortening procedure is performed to help tighten the extrinsic ligaments.37 For the wafer procedure, a radiofrequency wand and shaver are alternated back and forth to debride the central TFCC perforation. This provides excellent exposure of the ulnar head. A 4 mm bur is then usually brought in through the 6R or the 4/5 portal, and 3–4 mm of the ulnar head is removed (Fig. 9.9). Passive supination and pronation of the forearm is helpful in reaching the entire surface. Fluoroscopic imaging is also used to assess the amount of resection and reassess our positioning (Fig. 9.10). Great care must be taken to resect the distal ulna evenly so that there is a nice horizontal plane to its surface. The goal is to try and create approximately 1–2 mm of ulnar negative variance. The peripheral aspects of the ulna are quite challenging to bur down with a standard 4/5 or 6R portal, so a DRUJ portal can be useful. This is done by making a small longitudinal incision on top of the ulnar head just a few millimeters ulnar to the sigmoid notch and proximal to the TFCC proper. The forearm should be in pronation when this is done. The hemostat is then used to spread down between the ulnar head and the TFCC, and a trocar cannula can then be inserted into the DRUJ joint. The scope then may be placed in the 6R portal and the bur in the DRUJ portal, and the remaining bone removed by gradually supinating and pronating the forearm. Again, fluoroscopy is used to confirm the amount of resection. Wnorowski and colleagues58 have shown that excision of 3 mm of subchondral bone can reduce the force transmissions across the ulnar head by approximately 50%. Once this is completed, the instruments are removed and the incisions closed. The joint is injected with local anesthetic with epinephrine. A volar short arm splint is applied. This is usually removed at 1 week and the patient placed in a removable Orthoplast splint. Hand therapy is begun with active range of motion exercises. At approximately 8–10 weeks postoperatively, a strengthening program is begun. Both surgeon and patient should be aware that it can take 6 or more months for the symptoms to resolve

A

B

C FIGURE 9.14 A Case 3: Passing suture from outside to inside in order to repair the TFCC. B Repair prior to being tied down. C Repair tied and tightly secured.

Wrist Arthroscopy and TFCC Repair 131 completely. It is the author’s opinion, based on published results and personal experience, that patients with a fullthickness degenerative TFCC tear predictably improve after a TFCC debridement and a wafer resection for ulnar impaction.8 Extra-articular ulnar shortening can be accomplished with a variety of techniques or jig systems.59,60 Describing these techniques goes beyond the scope of this chapter. Most published series have shown improvement of ulnarsided wrist symptoms after ulnar shortening.61 Potential complications include non-union or delayed union of the osteotomy site. Patients often complain of irritation secondary to the hardware, which may require hardware removal once the osteotomy has healed. A

B

OPTIMIZING OUTCOMES For traumatic TFCC tears, one may simply excise the unstable central portion (up to two-thirds of the disc) leaving the peripheral attachments intact. This prevents any instability problems, and no demonstrable negative effects on forearm load transmission or stability have been shown. The work of Adams62 has shown that the peripheral 2 mm of the TFCC must be maintained so that instability does not develop. If there is a traumatic central tear in positive ulnar variance, the surgeon should consider ulnar shortening or a wafer procedure as well. For ulnar impaction, diagnostic arthroscopy is the best method for staging the amount of impaction. If a wafer procedure is chosen, pronating and supinating the wrist during the arthroscopy, rather than moving the scope and the shaver, can help ‘plan’ the resected distal ulna. Minimize trauma to the wrist during entry and exit of instruments. Bear in mind the dorsal ulnar sensory branch and branches of the dorsal radial sensory nerve. It is possible to incarcerate the dorsal ulnar sensory branch while cinching down the repair.

COMPLICATIONS

C FIGURE 9.15 A Case 4: Central degenerative (type II) tear. B RF ablation of the tear, leaving a stable rim. C LT ligament tear.

Fortunately, complications after wrist arthroscopy are relatively uncommon, and usually involve portal injuries to nerves or tendons.63 Other potential complications are related to traction and arm positioning. Complications related to hand surgery in general can include complex regional pain syndrome, dorsal sensory branch injuries, and tendon injuries. Rupture of the extensor pollicis longus after arthroscopy has been reported. Complications tend to be correlated with the difficulty of the procedure, with TFCC debridement less likely to result in complications than stabilization of fractures and ligaments.63 Precautions include avoiding iatrogenic injury to the cartilaginous surfaces, and minimizing the duration of arthroscopy to avoid MCP and PIP joint problems (as well as nerve injury from traction). Short surgical time also reduces the amount of fluid extravasation that can sometimes occur, which can cause swelling and potential carpal tunnel syndrome or compartment syndrome in the hand or forearm.


POSTOPERATIVE CARE For traumatic TFCC tears, early motion exercises follow simple debridement. However, if a TFCC repair was performed, most people utilize a sugar-tong or Munster type cast for at least 4–6 weeks, with the forearm in a position that best opposes the edge of repair determined at the time of surgery (usually mid-supination). After that, the patient is converted to an Orthoplast removable Munster splint and begins working on gentle wrist range of motion and forearm pronation/supination. At 10–12 weeks, strengthening is initiated. For degenerative-type tears, a resting short-arm splint can be used for 4 weeks, with gentle active range of motion and exercise of the wrist and forearm. Strengthening can be started at 6–8 weeks. If pinning of the lunotriquetral joint is required, then a short-arm cast for 6–8 weeks with pin removal at the time of cast removal is appropriate. Hand therapy or wrist range of motion exercises are then begun, and splinting discontinued by 12 weeks with a gradual progressive strengthening program. The importance of supervised hand therapy cannot be overstated.

CONCLUSION Tears of the TFCC can occur as a result of trauma as well as from repetitive degenerative mechanisms. The ulnar side of the wrist can be a diagnostic enigma because of its complex anatomy and multiple conditions that can cause pain in this region. A thorough history and physical examination, as well as diagnostic studies, are usually required to elucidate the cause of the pain. Arthroscopy is the gold standard for diagnosis, but must be weighed against its invasiveness. Palmer’s classification is useful for formulating treatment. Type IA lesions are usually debrided, whereas types IB, IC and ID are usually repaired by arthroscopic or open means. Type IIA/IIB degenerative tears are usually treated conservatively. Type IIC lesions may be treated by a wafer procedure or ulnar shortening. The type IID lesion may be addressed with arthroscopy, a wafer procedure, or ulnar shortening, the latter especially if there is an associated lunotriquetral ligament tear. For type IIE lesions, distal ulnar resection, Sauve–Kapandji arthrodesis, or prosthetic replacement are possible options. If there is a fixable or intercalated segmental instability accompanying a type IID lesion, then both ulnar shortening and pinning of the lunotriquetral joint should be considered. Diagnosis and treatment of these injuries can be challenging, but can also be quite rewarding.

REFERENCES 1. Trumble TE, Gilbert M, Vedder N. Arthroscopic repair of the triangular fibrocartilage complex. Arthroscopy 1996; 12: 588–597. 2. Viegas SW, Patterson RM, Peterson PD, et al. Ulnar-sided perilunate instability: an anotomic and biomechanical study. J Hand Surg [Am] 1990; 15: 268–278. 3. DeSmet L, DeFerm A, Steenwercks A, et al. Arthroscopic treatment of triangular fibrocartilage complex lesions of the wrist. Acta Orthop Clin North Belg 1996; 62: 8–13.

4. Bednar JM. Arthroscopic treatment of triangular fibrocartilage tears. Hand Clin 1999; 15: 479–488. 5. Osterman AL. Arthroscopic debridement of triangular fibrocartilage complex tears. Arthroscopy 1990; 6: 120–124. 6. Trumble TE, Gilbert M, Veddar N. Isolated tears of the triangular fibrocartilage: management by early arthroscopic repair. J Hand Surg [Am] 1997; 22: 807–813. 7. Bednar JM, Osterman AL. The role of the arthroscopy in the treatment of traumatic triangular fibrocartilage injuries. Hand Clin 1994; 10: 605–614. 8. Constantine KJ, Tomaino MM, Herndon HJ, et al. Comparison of the ulnar shortening osteotomy and the wafer section procedure as treatment for ulnar impaction syndrome. J Hand Surg [Am] 2000; 25: 55–60. 9. Cooney WP. Tears of the triangular fibrocartilage of the wrist. In: Cooney WP, ed. The wrist: diagnosis and operative treatment. St Louis: Mosby, 1998; 710–742. 10. Werner FW, Palmer AK, Fortino MD, et al. Force transmission through the distal ulna, effect of ulnar variance, lunate fossa angulation and radial and palmar tilt of the distal radius. J Hand Surg [Am] 1992; 17: 423–428. 11. Cooney WP. Evaluation of chronic wrist pain by arthrography, arthroscopy, arthrotomy. J Hand Surg [Am] 1993; 18: 815–822. 12. Palmer AK, Werner FW. The triangular fibrocartilage complex of the wrist: Anatomy and function. J Hand Surg [Am] 1981; 6: 153–162. 13. Kihara H, Short WH, Wernver FW, et al. The stabilizing mechanism of the distal radioulnar joint during pronation and supination. J Hand Surg [Am] 1995; 20: 930–936. 14. Bednar MS, Arnoczky SP, Weiland AJ. The microvasculature of the triangular fibrocartilage complex: its clinical significance. J Hand Surg [Am] 1991; 16: 1101–1105. 15. Adams BD, Samani JE, Holly KA, Triangular fibrocartilage injury: a laboratory model. J Hand Surg [Am] 1996; 21: 189–193. 16. Palmer AK, Glisson RR, Werner FW. Relationship between ulnar variance and triangular fibrocartilage complex thickness. J Hand Surg [Am] 1984; 9: 681–682. 17. Palmer AK, Werner FW, Glisson RR, et al. Partial excision of the triangular fibrocartilage complex. J Hand Surg [Am] 1988; 13: 391–394. 18. Werner FW, Glisson RR, Murphy DJ, et al. Force transmission through the distal radioulnar carpal joint: effect of ulnar lengthening and shortening. Hand Chir Mirochir Plast Chir 1986; 18: 304–308. 19. Freidman SL, Plamer AK, Short WH, et al. The change in the ulnar variance with grip. J Hand Surg [Am] 1993; 18: 713–716. 20. Freidman SL, Plamer AK, The ulnar impaction syndrome. Hand Clin 1991; 295–310. 21. Palmer AK. Triangular fibrocartilage complex lesions: a classification. J Hand Surg [Am] 1989; 14: 594–606. 22. Boulas HJ, Milek MA. Ulnar shortening for tears of the triangular complex. J Hand Surg [Am] 1990; 15: 415–420. 23. Chun S, Palmer AK. The ulnar impaction syndrome: follow up of ulnar shortening osteotomy. J Hand Surg [Am] 1993; 18: 46–53. 24. Mikic AD. Changes in the triangular fibrocartilage of the wrist joint. J Anat 1978; 126: 367–384. 25. Nakamura R, Horii E., Imaeda T, et al. The ulnocarpel stress test in the diagnosis of ulnar-sided wrist pain. J Hand Surg [Br] 1997; 22: 719–723. 26. Steyers CM, Balir WF. Measuring ulnar variance; a comparison of techniques. J Hand Surg [Am] 2000; 25: 352–357. 27. Uchiyama S, Terayama K. Radiographic changes in wrist with ulnar plus variance observed over a 10 year period. J Hand Surg [Am] 1991; 16: 45–48. 28. Tomaino MM. The importance of the pronated grip X-ray view in evaluating ulnar variance. J Hand Surg [Am] 2000; 25: 352–357. 29. Zimber EM, Palmer AK, Coren AB, et al. The triple injection wrist arthrogram. J Hand Surg [Am] 1998; 13: 803–809. 30. Levinsohn EM, Rosen ID, Palmer AK. Wrist arthrography: value of the three compartment injection method. Radiology 1191; 179: 231–239. 31. Kirschenbaum D, Sieler S, Solonick D, et al. Arthrography of the wrist. Assessment of the integrity of the ligaments in young asymptomatic adults. J Bone Joint Surg [Am] 1995; 77: 1207–1209.

Wrist Arthroscopy and TFCC Repair 133 32. Herbert TJ, Faithfull RG, McCann DJ, et al. Bilateral arthrography of the wrist. J Hand Surg [Br] 1990; 15: 233–235. 33. Hermansdorfer JD, Kleinman WB, Management of chronic peripheral tears of the triangular fibrocartilage complex. J Hand Surg [Am] 1991; 16: 340–346. 34. Mino DE, Paler AK, Levinsohn EM. The role of radiography and computerized tomography in the diagnosis of subluxation of dislocation of the distal radioulnar joint. J Hand Surg [Am] 1983; 8: 23–31. 35. Potter HG, Anis-Ernberg L. Weiland AJ, et al. The utility of high resolution magnetic resonance imaging in the evaluation of the triangular fibrocartilage complex of the wrist. J Hand Surg [Am] 1997; 79: 1675–1684. 36. Chung KC, Zimmerman NB, Travis MT. Wrist arthrography versus arthroscopy: A comparative study of 150 cases. J Hand Surg [Am] 1996; 21: 591–594. 37. Adams BD. Partial excision of the triangular fibrocartilage complex articular disc: a biomechanical study. J Hand Surg [Am] 1993; 18: 334–340. 38. Conca M, Conca R, Dalla Pria A. Preliminary experience of fully arthroscopic repair of triangular fibrocartilage complex lesions. Arthroscopy 2004; 20: 79–82. 39. Minami A, Ishikawa J, Suenaga N, et al. Clinical results of the treatment of triangular fibrocartilage complex tears by arthroscopic debridement. J Hand Surg [Am] 1996; 21: 406–411. 40. Ruch DS, Papadonikolakis A. Arthroscopically assisted repair of peripheral triangular fibrocartilage complex tears: factors affecting outcome. Arthroscopy 2005; 21: 1126–1130. 41. Ruch DS, Yang CC, Smith BP. Results of acute arthroscopically repaired triangular fibrocartilage complex injuries associated with intra-articular distal radius fractures. Arthroscopy 2003; 19: 511–516. 42. Bohringer G, Schadel-Hopfner M, Petermann J, Gotzen L. A method for all-inside arthroscopic repair of Palmer 1B triangular fibrocartilage complex tears. Arthroscopy 2002; 18: 211–213. 43. Zachee B, DeSmet L, Fabry G. Arthroscopic suturing for the TFC lesions. Arthroscopy 1993; 9: 242–243. 44. Millants P, De Smet L, Van Ransbeeck H. Outcome study of arthroscopic suturing of ulnar avulsions of the triangular fibrocartilage complex of the wrist. Chir Main 2002; 21: 298–300. 45. Skie MC, Mekhail AO, Deitrich DR, Ebraheim NE. Operative technique for inside-out repair of the triangular fibrocartilage complex. J Hand Surg [Am] 1997; 22: 814–817. 46. Trumble TE, Gilbert M, Vedder N. Ulnar shortening combined with arthroscopic repairs in the delayed management of triangular fibrocartilage complex tears. J Hand Surg [Am] 1997; 22: 807–813.

47. Baehser-Griffith P, Bednar JM, Osterman AL, Culp R. Arthroscopic repairs of triangular fibrocartilage complex tears. AORN J 1997; 66: 101–102, 105–111, quiz 112, 115, 117–118. 48. Cooney WP, Linscheid RL, Dobyns JH. Triangular fibrocartilage tears. J Hand Surg [Am] 1994; 19: 143–145. 49. Jantea CL, Baltzer A, Ruther W. Arthroscopic repair of the radialsided lesions of the fibrocartilage complex. Hand Clin 1995; 11: 31–36. 50. Sagerman SD, Short WH, Arthroscopic repair: a radial-sided triangular fibrocartilage complex tears. Arthroscopy 1996; 12: 339–342. 51. Short WH, Sagerman SD. TFC repair: radial-sided tear. In: Chow JCY, ed. Advanced arthroscopy. New York: Springer Verlag, 2001; 219–224. 52. Estrella EP, Hung LK, Ho PC, Tse WL. Arthroscopic repair of triangular fibrocartilage complex tears. Arthroscopy 2007; 23: 729–737. 53. Chidgey LK. The distal radioulnar joint: problems and solutions. J Am Acad Orthop Surg 1995; 3: 95–109. 54. Tomaino MM, Shah M. Treatment of ulnar impaction syndrome of the wafer procedure. Am J Orthop 2001; 30: 129–133. 55. Nagle DJ. Arthroscopic treatment of degenerative tears of the triangular fibrocartilage. Hand Clin 1994; 10: 615–624. 56. Felden P, Terrono A, Belsky M. Wafer distal ulna resection for triangular fibrocartilage tears and/or ulnar impaction. J Hand Surg [Am] 1992; 17: 731–737. 57. Gan BS, Richards RS, Roth JH. Arthroscopic treatment of triangular fibrocartilage tears. Orthop Clin North Am 1995; 26: 721–729. 58. Wnorowski D, Palmer AK, Werner FW, et al. Anatomic and biomechanical analysis of the arthroscopic wafer procedure. Arthroscopy 1992; 8: 204–212. 59. Labosky DA, Wagger CA. Oblique ulnar shortening osteotomy by a single saw cut. J Hand Surg [Am] 1996; 21: 4859. 60. Rayhack JM, Gasser SI, Latta LL, et al. Precision oblique osteotomy for shortening of the ulna. J Hand Surg [Am] 1993; 18: 9008–9018. 61. Van Sanden S, De Smet L. Ulnar shortening after failed arthroscopic treatment of triangular fibrocartilage complex tears. Chir Main 2001; 20: 332–336. 62. Adams BD. Partial excision of the triangular fibrocartilage complex articular disk: a biomechanical study. J Hand Surg [Am] 1993;18: 334–340. 63. Culp R. Complications of wrist arthroscopy. Hand Clin 1999; 15: 529–535.

CHAPTER

Wrist Reconstructive Procedures (Fractures and Dislocations)

10

Akio Minami and Tatsuya Masuko

SCAPHOID FRACTURES AND NONUNION Scaphoid fractures are common, generally occurring as a result of a fall on an outstretched hand or high-energy trauma. Waist fractures comprise about 75% of scaphoid fractures, proximal pole fractures about 20%, and distal pole or tubercle fractures about 5%. The retrograde blood supply to the scaphoid is from branches of the radial artery flowing from distal to proximal. Therefore, avascular necrosis of the proximal fragment occurs because of the tenuous blood flow to the proximal pole, which presents as a nonunion of the fractured scaphoid. Avascular scaphoid fracture or non-union may require vascularized bone graft, although the use of this technique is still controversial. Because the treatment of scaphoid non-union is quite difficult, early diagnosis of acute fractures and appropriate treatment, whether conservative or surgical, may prevent non-union. Untreated scaphoid non-union may lead to scaphoid non-union advanced collapse, or ‘SNAC’ wrist, for which there is no effective treatment.

Preoperative history and considerations

Imaging techniques Radiography

Posteroanterior, lateral, and oblique views are necessary. In addition, ‘scaphoid views’ are strongly recommended because non-displaced or minimally displaced scaphoid fractures are sometimes undetectable on these standard views. One of the scaphoid views is taken with the wrist extended and ulnarly deviated. However, even scaphoid views may not reveal occult or completely non-displaced fractures. In the normal wrist the scapholunate angle is between 30º and 60º and the capitolunate angle 0º. In contrast, >60º indicates a dorsal intercalated segmental instability (DISI) deformity.

Bone scintigraphy

Bone scintigraphy (technetium-99; 99mTc) is very useful when clinical signs of fracture are clear but the fracture cannot be detected by radiographs. A positive scan may reveal selected uptake at the fracture site, whereas diffuse uptake may suggest synovitis.

Mechanism of fracture

CT

The most common mechanism is a fall with the wrist extended because the scaphoid becomes vertical to the axis of forearm and the load is applied directly to the waist of the scaphoid.

CT is useful for evaluating the alignment of fractures. ‘Humpback’ deformity is detectable in sagittal images parallel to the long axis of the scaphoid. CT is also helpful for the assessment of bone bridging in healing scaphoid fractures.

Physical examination Swelling, ecchymosis, and tenderness are typically seen at the snuffbox. Limited and painful motion with radial and ulnar deviation is also observed. Grip strength is usually decreased. However, these signs are less prominent in chronic scaphoid fractures.

MRI For the evaluation of occult scaphoid fracture or avascular necrosis, MRI is the most suitable and reliable imaging technique. The fracture site exhibits low signal intensity on T1-weighted images.

135


Indications and contraindications Acute scaphoid fracture Primary treatment

An acute scaphoid fracture should be immobilized in a thumb spica cast. Even when the suspected fracture is not clear, it should be splinted. Repeated radiographs are taken after 2 weeks to detect whether a fracture exists or not, by showing bone resorption at the fracture site. MRI may be useful for early detection of fractures.

Conservative treatment Non-displaced (1 mm); (2) apparent angulation; (3) proximal pole fracture; (4) fracture comminution; and (5) fracture collapse. Open reduction and internal fixation has become more common because of better instrumentation and the availability of headless screws. Patients who are active and want to recover as early as possible should consider operative treatment. Proximal pole fractures are often difficult to treat successfully because the fracture is usually small and displaced, and the blood supply for the scaphoid is retrograde and sometimes not sufficient for union. The immobilization period is prolonged, and this may cause some complications, such as reduced motion and grip strength. Even with a long period of immobilization, the proximal pole fracture is likely to result in non-union or delayed union. For this fracture pattern, early open reduction and internal fixation may be preferable.

Approach A dorsal approach is suitable for proximal pole fractures and the volar approach is used for waist and distal pole fractures.

insufficient immobilization, insufficient fixation, and comminution. After curettage and removal of non-viable bone from the proximal and distal scaphoid, a large corticocancellous bone graft is placed into the excavated cavity. The graft is usually from the corticocancellous iliac crest or radius. Scaphoid non-union may lead to a progressive arthritis so called SNAC (scaphoid non-union advanced collapse). Once symptomatic SNAC wrist deformity sets in, salvage operations include proximal row carpectomy, prosthetic or allograft replacement, partial scaphoid excision, wrist denervation, and arthrodesis.

Operative treatment MRI and CT are useful for evaluation of non-union. Avascular necrosis is detectable on MRI. ‘Humpback’ deformity means that the fractured scaphoid is collapsed and needs internal fixation with a volar wedge bone graft. Sagittal CT scan views can detect the ‘humpback’ deformity and are useful for preoperative planning. ● With or without avascular necrosis Scaphoid nonunion with avascular necrosis may be treated with internal rigid fixation and vascularized bone graft, whereas scaphoid non-union without avascular necrosis is treated with internal fixation and non-vascularized cancellous bone graft, although the most appropriate treatment for this condition is still debated. One, two, or two/three intercompartmental supraretinacular artery (ICSRA) grafting is used for vascularized bone grafting. Both arteries are branches of the radial artery that lies between the first, second, or second and third extensor compartments, and the blood flow is retrograde. ● Approach Proximal pole necrosis is approached dorsally, and waist and distal pole necrosis volarly. ● Implant Headless screws are preferred. Rigid fixation can shorten the time to union. K-wires are used only for preliminary fixation or as a ‘joystick’ to distract the scaphoid fracture, not as the sole fixation method. ● Immobilization The wrist is immobilized in a short arm thumb spica splint for 2 weeks, followed by a short arm cast or splint for 6–8 weeks until union. In nonunion cases the period until union is usually longer than for acute fractures.

Implant Headless screws are used for scaphoid fractures. Other fixation devices include K-wires, screws, and staples. Less displaced fractures are fixed without bone grafting, but displaced ones need grafting. Minimally displaced or nondisplaced fractures may be treated with percutaneous fixation as reported by Slade et al.1 to minimize soft tissue damage.

Immobilization The wrist is immobilized in a short arm thumb spica splint for 2 weeks, followed by a short arm splint for 6–8 weeks until union.

Scaphoid non-union Delayed diagnosis and treatment of proximal pole fractures is the crucial risk factor for scaphoid non-union as well as

Operative approach

Dorsal percutaneous fixation Dorsal percutaneous fixation without bone grafting is applied to non-displaced or minimally displaced scaphoid fractures. Image intensifier is necessary. Slade et al.1,2 reported using this method with satisfactory results. They also reported using this technique for scaphoid non-unions3 (Fig. 10.1).

Procedure The wrist is pronated and flexed to make a radiograph ‘ring sign’ of the scaphoid. A guide wire is inserted from dorsal to volar, aiming at the center of the scaphoid as the fracture is reduced. Another wire is inserted to prevent fragment displacement or rotation during drilling with the

Wrist Reconstructive Procedures 137 necrotic bone at the site of non-union are debrided using a curette or burr. The displaced fragment is reduced with Kwires. After reaming and measuring the length, a screw is placed with the wrist flexed. Image intensification is necessary for checking screw position and length.

Volar approach to the scaphoid A volar approach is indicated for waist and distal fractures. A 4–5 cm longitudinal incision is placed along the radial border of the thenar eminence and along the flexor carpi radialis (FCR) tendon. This is released and retracted ulnarly, and the radioscaphocapitate ligament the capsule incised longitudinally. The fracture site is identified and the fibrous tissue and necrotic bone at the non-union site are debrided. Assisting K-wire is recommended to prevent scaphoid rotation during screw fixation. The screw is inserted distally at the scaphotrapeziotrapezoidal joint to the proximal fragment. Humpback deformity or comminution requires bone grafting from the radius or iliac bone. The grafted bone is wedge-shaped to fit into the fracture site and fixed internally with a Herbert screw. Rüsse4 reported using a corticocancellous strut graft to the scaphoid fracture. The cortex of the grafted bone is wedged into the non-union site to give structural support for better union (Fig. 10.3).

Dorsal approach to the scaphoid with vascularized bone graft FIGURE 10.1 Dorsal percutaneous fixation reported by Slade et al.

cannulated hand reamer. Alternatively, the guide wire is advanced to exit the volar skin and a hemostat is clamped on the volar wire. Appropriate screw length is key to this procedure. The screw is typically 2–4 mm shorter than measured because the headless screw will be countersunk and the differential pitch of the screw will shorten the scaphoid after compression. The screw is inserted under image intensifier guidance (Fig. 10.2).

Volar percutaneous fixation Minimally displaced waist and distal pole fractures are treated with volar percutaneous fixation. After an incision at the scaphotrapezial joint, a guide wire is inserted from the volar, distal to the dorsal, proximal scaphoid with the wrist extended. Image intensification is used to guide the selection of screw length. This procedure requires a great deal of precision to prevent impingement of the screw on the surrounding structures, or misdirected placement.

Dorsal approach for the proximal scaphoid fracture The dorsal approach is preferable for proximal pole fractures because the exposure is easier and more screw threads can engage the pole. An incision is made between the third and fourth compartments. The EPL is retracted radially and the dorsal capsule over the scapholunate joint is incised. The fracture site is identified and the fibrous tissue and

One, two, or two/three ICSRA is selected for the bone graft. The waist or proximal pole non-union is approached dorsally for ease of harvesting the vascularized bone graft. An incision is placed between the third and fourth compartments and the extensor pollicis longus (EPL) tendon is retracted radially. The wrist capsule is incised longitudinally and the scaphoid non-union site identified. The fibrous tissue and necrotic bone at the non-union site are debrided and curetted. One, two, or two/three ICSRA are identified between the first and second compartments or the second and third compartments, respectively. These retinacula are released and the bone graft is harvested. We mark the appropriate size of graft using K-wire drilling. Then an osteotome is used to chisel along the drill holes to avoid fracturing the graft. The vessel is mobilized with the bone graft to rotate and insert into the non-union site. A headless screw is then placed.

Volar approach to the scaphoid with vascularized bone graft A volar approach is indicated for scaphoid non-union with avascular necrosis or humpback deformity. The vascularized bone graft is supplied by the radial branch of the palmar radiocarpal arch. A 4–5 cm longitudinal incision is placed along the radial border of the thenar eminence and along the FCR tendon. The FCR sheath is released and the FCR retracted ulnarly, and the capsule is incised longitudinally. The non-union site is identified and debrided. The vascularized bone graft is harvested and elevated from the ulnar aspect of the distal


B

A

D C FIGURE 10.2 Radiographs after dorsal percutaneous fixation followed by the Slade procedure. A Preoperative radiograph (oblique view). The scaphoid fracture is undisplaced. B MRI (T1-weighted image). The fractured scaphoid shows low intensity; the triquetrum is also fractured. C MRI (T2-weighted image). The fractured scaphoid shows high intensity. D Four-week postoperative radiograph showing the healed fracture line.

radius and crafted into a wedge shape to fit the humpback deformity, if present. The fracture is fixed internally with a Herbert screw.

Complications and side effects Conservative treatment using cast immobilization can lead to pressure neuritis, capsular stiffness, or complex regional pain syndrome. In operative treatment, sensory neuritis, displaced or extruded grafts, pin tract infections, non-union, or recurrence of deformity are potential complications.

Postoperative care Casts are usually changed at 3 and 8 weeks, and repeated radiographs are taken to confirm healing and alignment of bone fragments. If scaphoid union is suspected not to occur, a tomogram or CT scan may be considered. An additional 4 weeks of casting may be warranted.

Conclusions Scaphoid fractures are very common. Non-displaced or minimal displaced fractures are sometimes difficult to

Wrist Reconstructive Procedures 139

Standard Rüsse graft

Winged graft

FIGURE 10.3 A corticocancellous strut bone graft reported by Rüsse.4

diagnose. It is not rare for tenderness at the snuff-box to be the only symptom. Improper or delayed treatment causes delayed union or non-union, and can lead to SNAC wrist. Given the gravity of non-healing scaphoid fractures, in suspected cases CT and MRI are helpful for diagnosing and planning treatment. Conservative immobilization in a long or short arm spica cast for more than 6 weeks is the standard treatment for non-displaced or minimally displaced fractures. However, conservative treatment requires a long period of immobilization and non-union occasionally occurs. We recommend operative treatment even for non-displaced or minimally displaced fractures, especially for manual workers or highly active patients.

Greater arc Lesser arc

PERILUNATE DISLOCATIONS Perilunate dislocations are rare. The mechanism of injury is severe trauma, such as a traffic accident or a fall from a height onto a hyperextended wrist. Perilunate dislocation is classified into two types: perilunate or lunate. This categorization can be further subdivided into those with or without associated fractures. The former is a greater arc injury and the latter is a lesser arc injury (Fig. 10.4). The lesser arc injury is a pure ligamentous disruption, whereas a greater arc injury involves fractures of the surrounding carpal bones, such as the scaphoid and/or capitate. This section describes the lesser arc injury.

Preoperative history and considerations

FIGURE 10.4 A greater arc and a lesser arc injury.

Stage III: Dissociation at lunotriquetral joint. The relationship between the lunate and the triquetrum disrupts. The dorsal perilunate dislocation occurs. ● Stage IV: Complete palmar lunate dislocation. The lunate is completely dislocated palmarly. Other injuries such as a palmar perilunate dislocation and an isolated dorsal lunate dislocation are quite rare and not reproducible. ●

Mechanism of injury

Physical examination

From laboratory research the mechanism of perilunate dislocation is thought to occur with wrist extension, ulnar deviation, and intercarpal supination sustained during high-velocity trauma or falls from a considerable height. Mayfield et al.5 reported that the disruption of ligaments may cause lunate dislocation, and this injury is classified into four stages (Fig. 10.5). ● Stage I: Scapholunate dissociation. The relationship between the scaphoid and the lunate disrupts. ● Stage II: Lunocapitate dissociation. The relationship between the capitate and the lunate disrupts.

The injured wrist has significant swelling, local heat, ecchymosis, and pain. Pain with motion in the wrist and fingers is quite severe, causing reduced motion. Carpal tunnel syndrome symptoms are observed. The palmarly dislocated lunate may compress the medial nerve, and the direct injury may damage the median or ulnar nerves.

Imagings

Radiographs Anteroposterior (AP) or posteroanterior (PA), lateral, and oblique wrist views are taken. If these standard radiographs


I

II Scapholunate dissociation

Lunocapitate dissociation

Lunotriquetral dissociation

Palmar flexion of lunate

III

IV

FIGURE 10.5 Classification of perilunate dislocations. Stage I: Scapholunate dissociation. Stage II: Lunocapitate dissociation. Stage III: Dissociation at lunotriquetral joint. Stage IV: Complete palmar lunate dislocation.

are unclear, traction views can be useful. The lateral view should be a true lateral with the wrist in neutral to prevent misdiagnosis. Normally, perilunate dislocations are easily visualized on true lateral views. Gilula et al.6,7 reported three carpal lines (or arcs), named ‘Gilula’s lines (or arcs),’ in the AP view (Fig. 10.6). One of these three lines contains the proximal articular surface of the proximal carpal row. The second is an outline of the distal articular surface of the proximal row. The third is a line over the proximal articular surface of the distal carpal row. Disruption of Gilula’s lines reveal ligamentous injuries or fractures of the wrist. The ‘ring sign’ is seen when the scaphoid is flexed because of scapholunate ligamentous injury in which the distal pole of the scaphoid superimpose on the rest of the bone. The ‘Terry Thomas sign’ is an increased gap between the scaphoid and lunate of more than 2 mm, suggesting scapholunate dissociation and perilunate injury. Fractures

of the scaphoid, capitate, hamate, or triquetrum indicate a greater arc injury. The midcarpal joint is displaced or dislocated dorsally, as shown in Figure 10.5 (stage III). The triangular or wedgeshaped lunate in AP view means that the lunate is dislocated. The ‘spilled teacup’ sign in a true lateral view shows that the lunate is dislocated palmarly and palmarly flexed. The flexed scaphoid suggests disruption of the relationship between the scaphoid and the lunate. An increased radiolunate angle (>15º) and/or an increased scapholunate angle (>70º) indicates DISI (dorsiflexed intercalated segment instability) deformity.

Arthrography Arthrography is a useful method for diagnosing wrist ligamentous injuries. Perilunate dislocations, however, are

Wrist Reconstructive Procedures 141 flexed scaphoid is reduced and fixed percutaneously. The wrist is immobilized in a short arm cast for 10 weeks.

Open reduction and repair of scapholunate interosseous ligament (SLIL)

III II I

FIGURE 10.6 Gilula’s line (or arc). I: proximal articular surface of the proximal carpal row. II: distal articular surface of the proximal carpal row. III: proximal articular surface of the distal carpal row.

usually clear on plain radiographs. Therefore, arthrography is rarely indicated.

CT, MRI, and bone scintigraphy These are usually not needed for this condition, unless an occult fracture is suspected.

Treatments

Acute treatment

Closed reduction and cast immobilization Closed reduction is useful as a temporary measure for pain relief and restoration of anatomical architecture. After continuous traction, closed reduction is performed by manipulation: the wrist is extended and the lunate pushed dorsally from the volar wrist to engage the dorsal lip of the lunate on the capitate. Then the wrist is gradually flexed and direct pressure applied to the capitate to seat it on the lunate. After reduction, the alignment is checked by radiographs. If the alignment is acceptable, one may choose cast immobilization for 10 weeks, but the choice of nonoperative treatment is controversial because healing the avulsed ligaments may be more secure with an open approach.

Closed reduction and percutaneous pinning If the wrist is not stable after the closed reduction, an additional procedure is necessary to restore carpal alignment and maintain the reduction. Percutaneous pinning may be carried out. Procedure After anatomical reduction, a 0.045-inch K-wire is inserted percutaneously from the radius to the lunate, and then from the triquetrum to the lunate. Next, the

The authors8 previously reported the open reduction and ligament repair procedure. A dorsal longitudinal incision centered over Lister’s tubercle exposes the dorsal retinaculum, which is divided over the EPL. This tendon is retracted radially, and the joint is exposed through a straight capsular incision in line with Lister’s tubercle. The entire capsuloligamentous complex is reflected. The proximal pole of the scaphoid, having rotated dorsally and radially, will protrude vertically into the wound. Retracting the scaphoid radially exposes the head of the capitate, which is frequently dislocated dorsal to the lunate. On the palmar side, a routine carpal tunnel incision is extended proximally across the wrist. The flexor tendons and median nerve are retracted radially, revealing a consistent transverse rent in the palmar capsule. This tear is present in all the authors’ patients with both dorsal perilunate and palmar lunate dislocations. The lunate is now easily reduced under direct vision from the palmar approach by manually pushing it back between the capitate and radius while an assistant applies gentle longitudinal traction on the hand. Although it is virtually impossible to identify and repair the individual intercapsular ligaments, it is relatively easy to repair the volar rent in the capsuloligamentous complex using interrupted non-absorbable sutures. It is important to preserve the continuity of the palmar capsuloligamentous complex, which is the important stabilizer for the wrist. Dorsally the proximal pole of the capitate is reduced into the distal concavity of the lunate under direct vision. The proximal pole of the scaphoid, which has been displaced dorsally and radially by the injury, is rotated back into its normal anatomic position. The SLIL is usually torn from its scaphoid attachment. Minimum debridement of the torn end of the SLIL is performed, and then three drill holes are made at the notch of the scaphoid (lunate facet). Non-absorbable sutures are tightly tied to approximate the edge of the torn SLIL through drill holes in the scaphoid, after anatomic reduction of the carpal bones. Three K-wires are inserted to stabilize the three key elements: scaphoid, lunate, and capitate. The wrist is immobilized in a long arm splint with thumb spica for 2 weeks. K-wires are removed 6–8 weeks postoperatively. Part-time splinting is continued for an additional 6 weeks.

Open reduction and reconstruction of the SLIL

The authors8 have reported the procedure of open reduction and reconstruction of the SLIL for symptomatic chronic scapholunate ligament tear. Combined palmar and dorsal approaches as described for repair of the SLIL are employed. From the dorsal incision, the gap between the scaphoid and lunate is often filled with fibrous tissue, and extensive soft tissue dissection may be required to free up the scaphoid adequately to permit correction of its subluxation. Exces-

142 Hand and Upper Extremity Reconstruction sive soft tissue stripping should be avoided because it may create further instability and result in devascularization of the scaphoid. A 10-cm strip of the ulnar half of the ECRL is prepared, leaving the distal end attached at its insertion. A hole is drilled from the dorsal aspect of the proximal pole of the scaphoid, emerging on the scapholunate interarticular surface palmar to its center. A similar hole is drilled from the dorsal aspect to the lunate, emerging opposite the scaphoid tunnel. The final diameter of this tunnel should be large enough to accept a 4 mm Hunter tendon implant, which is used as the tendon passer. A curved ligature carrier can also be used to thread the tendon graft through the holes. The graft is then passed from scaphoid to lunate, prior to actual reduction and fixation of the bones. After the bones have been reduced and stabilized with K-wires, the graft is pulled through the tunnel and placed under slight tension. The graft, which emerges from the dorsal opening in the lunate, is then brought back across the scapholunate interval, sutured to itself, and further reinforced by tacking it to the strong dorsal capsular fibers over the triquetrum or, alternatively, into the dorsal periosteum of the distal radius. All possible repairs of available ligamentous tissue are then carried out to further reinforce the dorsal capsule. The wrist is immobilized in a long arm splint with thumb spica for 2 weeks. K-wires are removed 6–8 weeks postoperatively. Part-time splinting is continued for an additional 6 weeks.

Chronic perilunate dislocations (delayed presentation) If the injury occurred 3–12 weeks before presentation, open reduction of the perilunate dislocation and ligament repair are indicated. The procedures of the open method for chronic perilunate dislocation are the same as those of the acute one. However, the outcomes of chronic perilunate dislocations are worse than those of acute dislocation. If reduction is not possible, salvage methods such as proximal row carpectomy, partial wrist arthrodesis, or total wrist arthrodesis are considered. Wrist arthrodesis is a good indication for patients who need maximum strength.

Complications Complications of perilunate dislocations are common. Symptomatic arthritic changes can be treated with salvage procedures. Median nerve neuropathy is also common. Early reduction of the dislocated lunate may prevent the neuropathies. Avascular necrosis of the scaphoid or the lunate has been reported. The former may occur with greater arc injuries, and the latter when the blood supply to the lunate is damaged. Carpal instability may occur at the scapholunate or lunotriquetral articulation and will require a salvage procedure.

Conclusions Perilunate dislocations are rare injuries. Diagnosis is not difficult, especially for stages III and IV. However, the treat-

ments are troublesome because most dislocations are a result of high-energy injuries. Early reduction and ligament repairs are crucial.

SCAPHOLUNATE INSTABILITY Scapholunate instability is the most frequent form of carpal instability. The characteristics of scapholunate instability are abnormal scaphoid and lunate motion; dorsiflexed intercalated segment instability (DISI) deformity; dorsal subluxation of the lunate; and proximal migration of the capitate. The separation between scaphoid and lunate is often shown in neutral posteroanterior (PA) radiographs without provocative tests. This means that this instability or dissociation is static. Scapholunate instability that appears only after provocative tests are performed is termed dynamic.

Preoperative history and considerations Mechanism of injury

Armstrong9 reported that scapholunate dissociation occurred when the wrist was in extension and in ulnar deviation for activities such as grasping a cylindrical object, for example a racquet handle or motorcycle handlebar. Mayfield et al.5 also reported that this injury happened with the wrist in extension, ulnar deviation, and midcarpal supination. The dissociation of scaphoid and lunate causes the scaphoid to flex while the other proximal carpal row bones, such as the lunate and triquetrum, extend.

Physical examination Patients usually complain of pain dorsally over the SLIL and weakness with loading of the wrist. The Watson maneuver or the scaphoid shift test is well known for the diagnosis of scapholunate instability.

Scaphoid shift test The wrist is moved manually into full ulnar deviation with the forearm pronated. In this position, the scaphoid is moved to be in extension. As the wrist is moved into radial deviation, the distal pole of the scaphoid is prevented from flexing by the examiner’s thumb. The proximal pole of the scaphoid is forced to sublux dorsally and produce pain, which reveals a scapholunate dissociation.

Scaphoid displacement test The scaphoid tuberosity is pushed from volar to dorsal with the wrist in ulnar deviation. If the scaphoid is displaced to ride out of the radial fossa over the dorsal rim and accompanied by a painful snap, the test is positive.

Imaging

Radiography (AP or PA views) ●

Scapholunate gap: A diastasis between the scaphoid and lunate >2 mm is abnormal and is suspicious for scapholunate instability.

Wrist Reconstructive Procedures 143 ●

●

●

Ring sign: The distal pole of the flexed, perpendicular scaphoid appears as a ‘ring’ because of disruption of the scapholunate relationship. Quadrilateral appearance of the lunate: As the lunate rotates dorsally, it appears to be quadrilateral in shape. Disruption of Gilula’s lines: Disruption of one of three arcs means a ligamentous injury or a carpal fracture.

Radiography (lateral views) ●

●

●

Subluxation of the proximal pole of scaphoid: As the scaphoid is flexed, the proximal pole is driven to the dorsal rim of the radius. Increased radiolunate angle: More than 15º is suspicious of DISI deformity. Increased scapholunate angle: The normal range of the scapholunate angle is 30–60º. More than 70º means the link between the scaphoid and lunate is broken.

Magnetic resonance imaging (MRI) MRI can identify the scapholunate ligament as a low-intensity band on T1-weighted scans. Usually the intact ligament can be seen as two successive images. MRI can also demonstrate loss of continuity, fraying, thinning, and irregularity of the ligament.

Arthrography The main indication for arthrography is ‘dynamic’ instability of a scapholunate ligament. Although routine radiographs can detect ‘static’ instability, ‘dynamic’ instability is sometimes difficult to evaluate from normal X-rays. Arthrography can allow direct inspection of the SLIL and evaluation of other ligaments.

Treatments

Acute scapholunate dissociation Cast immobilization

After manual reduction of the scaphoid, cast immobilization is applied. However, this treatment is often unsuccessful.

Open repair The carpal bones are exposed through a dorsal longitudinal incision. A triangular incision between the radiotriquetral and triquetroscaphoid ligaments is made to expose the wrist joint; 0.062-inch K-wires are drilled into the lunate and scaphoid and used as joysticks to manipulate the two bones. Because the SLIL is usually torn off the scaphoid, multiple small drilling holes are made from the proximal convex rim of the scaphoid to the dorsolateral ridge. After reduction and pinning of the scaphoid and lunate, several mattress sutures are tied through the scapholunate interosseous membrane and the dorsal ligament, and the scapholunate relationship is internally fixed with a number of K-wires for 8–10 weeks. The midcarpal joint may be fixed with K-wires for greater stability. Bone anchors are also useful for repairing the SLIL (Fig. 10.7).

Chronic scapholunate dissociation without osteoarthritis Dorsal capsulodesis

Blatt10 reported that a capsuloligament from the dorsal capsule of the wrist can be attached to the distal pole of the scaphoid to prevent its flexed posture. Although this method is not directly effective in dissociation of the scaphoid and the lunate, satisfactory clinical results were reported. Procedure A 1–1.5 cm wide flap is harvested from the ulnar dorsal wrist capsule. The distal insertion is released and attached to the distal pole of the scaphoid using a bone anchor. The wrist is immobilized for 4 weeks in a long arm cast, and then for 4 weeks in a short arm splint.

Ligament reconstruction

Brunelli et al.11 reported the ligament reconstruction procedure using a slip of the FCR tendon. Procedure The wrist is approached dorsally through a 4-cm longitudinal incision and the extensor retinaculum divided between the second and third compartments. The scar tissue between the scaphoid and lunate is excised. The fibrous sheath of the FCR tendon is incised and a 2–3 mm strip of the tendon harvested longitudinally, leaving it attached to the base of the index metacarpal. The tendon slip is passed from volar to dorsal through a 2.5-mm diameter tunnel in the distal scaphoid, parallel to its distal articular surface. The scaphoid is reduced and the scapholunate dissociation corrected. The distal part of the scaphoid and the capitate are fixed with K-wires, and the tendon slip is sutured to the dorsum of the SLIL and to the dorsal distal lip of the radius. The new modification of this technique does not suture the tendon graft to the radius to avoid reduced wrist motion. The wrist is immobilized for 4–6 weeks (Fig. 10.8). The authors8 have reported another procedure for ligament reconstruction, as follows. From the dorsal incision, a 10-cm strip of the ulnar half of the ECRL is harvested, leaving the distal end attached at its insertion. A hole is drilled from the dorsal aspect of the proximal pole of the scaphoid, emerging on the scapholunate interarticular surface palmar to its center. A similar hole is drilled from the dorsal aspect to the lunate, emerging opposite the scaphoid tunnel. The final diameter of this tunnel should be large enough to accept a 4 mm Hunter tendon implant, which is used as the tendon passer. A curved ligature carrier can also be used to thread the tendon graft through the tunnel. The graft is then passed from scaphoid to lunate, prior to actual reduction and fixation of the bones. After the bones have been reduced and stabilized with K-wires, the graft is pulled through the tunnel snugly and placed under slight tension. The graft, which emerges from the dorsal opening in the lunate, is then brought back across the scapholunate interval, sutured to itself, and further reinforced by tacking it to the strong dorsal capsular fibers over the triquetrum, or alternatively, into the dorsal periosteum of the distal radius. All possible repairs of available ligamentous tissue are then carried out to further reinforce the dorsal capsule.

144 A

B

C

D

FIGURE 10.7 Open repair procedure for acute scapholunate dissociation. FIGURE 10.8 Ligament reconstruction procedure reported by Brunelli et al.11

1/2 of FCR tendon passed through distal pole of scaphoid

FCR tendon sutured to scapholunate interface and ulnar side of distal radius


A

B

FIGURE 10.9 Radiograph of four-corner fusion procedure for SNAC wrist (not for SLAC wrist). A Preoperative radiograph. Osteoarthritic change is shown at the radiocarpal joint. The articular surface between the radius and the lunate is not affected. B Postoperative radiograph. The nonunited scaphoid is excised and the lunate, capitate, triquetrum, and hamate are fixed with K-wires.

146 Hand and Upper Extremity Reconstruction ●

●

C FIGURE 10.9, cont’d C Postoperative radiograph showing the united carpal bones.

Arthrodesis

Fusion of the scaphoid, trapezium, and trapezoid (STT) Peterson et al.12 reported a partial wrist arthrodesis for the scaphoid, trapezium, and trapezoid in the treatment of rotatory subluxation of the scaphoid. Watson et al.13 applied STT fusion to the treatment of chronic scapholunate dissociation before the appearance of osteoarthritic changes. This procedure can restore the height of the radial carpus. It decreases the flexion–extension motion arc by 20–30% and radioulnar deviation motion by 34–40% postoperatively.

Chronic scapholunate dissociation with osteoarthritis (SLAC wrist)

Watson et al.14 called osteoarthritis resulting from scapholunate instability or dissociation ‘scapholunate advanced collapse’ (SLAC). SLAC wrist is classified into three stages and operations are designed based on these stages. ● Stage I: arthritis at the radial styloid Arthritic change in SLAC wrist usually begins between the scaphoid and the radial styloid. Styloidectomy or STT fusion with radial styloidectomy is performed for pain relief.

Stage II: arthritis at the entire radiocarpal joint Arthritis has progressed to the radiocarpal joint. An attempt to relocate and preserve the scaphoid by ligament reconstruction or by STT fusion will fail. Four-corner fusion or proximal row carpectomy is indicated. Stage III: arthritis at the capitolunate joint Arthritis has progressed to the capitolunate joint. The articular surface of capitate is too degenerate to use for proximal row carpectomy. The indicated operations are fourcorner fusion, total wrist fusion, or total wrist arthroplasty. ● Four-corner fusion The scaphoid is excised and the other carpal bones are fused. The resultant bone block articulates on the lunate fossa. ● Procedure The wrist is approached through a longitudinal dorsal incision and the scaphoid excised piece by piece or as a block. The articular surfaces of the lunate, capitate, triquetrum, and hamate are denuded and decorticated. The lunate is reduced into a neutral position if DISI deformity is present. These bones are fixed with Kwires, screws, staples, or plates such as a circular plate. The bone graft from the excised scaphoid is tightly packed into the intercarpal spaces. The wrist is immobilized in a short arm cast for 4–8 weeks until union (Fig. 10.9). ● Proximal row carpectomy After removal of the proximal carpal row bones, the capitate articulates with the radius in the lunate fossa. Usually, the lunate fossa of the radius remains intact in stage II. If severe degenerative change is present, other operations should be selected. ● Procedure A longitudinal dorsal exposure of the wrist is used. The carpus is exposed between the third and fourth compartments, and flaps are raised ulnarly and radially. The proximal carpal bones are excised by first removing the lunate. The new radiocapitate joint is temporally fixed with K-wires, if necessary. A volar short arm splint is placed with the wrist in 10º of extension for 3–6 weeks. K-wires are removed after 3–4 weeks (Fig. 10.10).

Conclusions Scapholunate instability is the most frequent form of carpal instability. The dissociation of the scaphoid and lunate may not be clear, and wrist arthrography is useful to establish the diagnosis and plan treatment. A variety of approaches outlined above will tailor treatment based on the progression of disease.


A

B

FIGURE 10.10 Radiograph of the proximal row carpectomy procedure for SLAC wrist. A Preoperative radiograph showing osteoarthritic change at the radiocarpal joint and scapholunate dissociation. B Postoperative radiograph. The scaphoid, the lunate, and the triquetrum are excised and the new radiocapitate joint is temporally immobilized with K-wires.

REFERENCES 1. Slade JF 3rd, Grauer JN, Mahoney JD. Arthroscopic reduction and percutaneous fixation of scaphoid fractures with a novel dorsal technique. Orthop Clin North Am 2001; 32: 247–261. 2. Slade JF 3rd, Gutow AP, Geissler WB. Percutaneous internal fixation of scaphoid fractures via an arthroscopically assisted dorsal approach. J Bone Joint Surg [Am] 2002; 84-A: 21–36. 3. Slade JF 3rd, Geissler WB, Gutow AP, Merrell GA. Percutaneous internal fixation of selected scaphoid non-unions with an arthroscopically assisted dorsal approach. J Bone Joint Surg [Am] 2003; 85-A: 20–32. 4. Rüsse O. Fracture of the carpal navicular. Diagnosis, non-operative treatment, and operative treatment. J Bone Joint Surg [Am] 1960; 42-A: 759–768. 5. Mayfield JK, Johnson RP, Kilcoyne RK. Carpal dislocations: pathomechanics and progressive perilunar instability. J Hand Surg [Am] 1980; 5: 226–241. 6. Gilula LA. Carpal injuries: analytic approach and case exercises. AJR Am J Roentgenol 1979; 133: 503–517. 7. Peh WC, Gilula LA. Normal disruption of carpal arcs. J Hand Surg [Am] 1996; 21: 561–566.

8. Minami A, Kaneda K. Repair and/or reconstruction of scapholunate interosseous ligament in lunate and perilunate dislocations. J Hand Surg [Am] 1993; 18: 1099–1106. 9. Armstrong GW. Rotational subluxation of the scaphoid. Can J Surg 1968; 11: 306–314. 10. Blatt G. Capsulodesis in reconstructive hand surgery. Dorsal capsulodesis for the unstable scaphoid and volar capsulodesis following excision of the distal ulna. Hand Clin 1987; 3: 81–102. 11. Brunelli GA, Brunelli GR. A new technique to correct carpal instability with scaphoid rotary subluxation: a preliminary report. J Hand Surg [Am] 1995; 20: S82–85. 12. Peterson HA, Lipscomb PR. Intercarpal arthrodesis. Arch Surg 1967; 95: 127–134. 13. Watson HK, Hempton RF. Limited wrist arthrodeses. I. The triscaphoid joint. J Hand Surg [Am] 1980; 5: 320–327. 14. Watson HK, Ballet FL. The SLAC wrist: scapholunate advanced collapse pattern of degenerative arthritis. J Hand Surg [Am] 1984; 9: 358–365.

CHAPTER

11

Arthrodesis Techniques Takaya Mizuseki

INTRODUCTION With the advancement of medical technology and the pursuit of a better quality of life, new types of arthroplasty procedure are being devised for small joints. Some of them have withstood the test of time and are being accepted in place of arthrodesis, whereas others have not. Even with the revolutionary improvement in arthroplasty procedures, arthrodesis is still the most reliable method to stabilize the joint and alleviate pain. When appropriately indicated and performed, arthrodesis provides reasonable results.

PREOPERATIVE CONSIDERATIONS Before embarking on arthrodesis, it is mandatory to look for every possible way to preserve joint function, including debridement and osteotomy.1 To fuse the joint means to stabilize and alleviate pain by sacrificing motion. The cost of fusion is substantial.

Position of arthrodesis The optimal position for arthrodesis differs by joint location, gender, and disease type. The recommended position of wrist fusion differs from disease to disease and from person to person. Generally speaking, in the normal working population fusion in slight extension is preferred, with the wrist in a neutral degree of radioulnar deviation.2 For the rheumatoid wrist, the preferred angle of fusion is still debatable.3–6 The author prefers a slightly flexed wrist position on the dominant hand, and a slightly extended position on the non-dominant hand, as for the rheumatoid patient hygiene and perineal care are easier with a flexed wrist. For thumb fusion, the recommended angle of the carpometacarpal (CMC) joint fusion is 45º of palmar abduction and 20º of radial abduction for manual workers, and 30–40º radial abduction for women (Fig. 11.1). Women and

non-manual workers more often complain of inability to make a ‘flat hand’ after surgery than do manual workers, for whom stronger grasp is more important, so that for those to whom push-up with an open hand is important it is wise to give the thumb more radial abduction. The thumb metacarpophalangeal (MP) joint is fused in slight flexion if the interphalangeal (IP) and the CMC joints are intact. It should be fused with more flexion if the thumb IP joint has a tendency towards hyperextension contracture. The thumb IP joint is fused in 0–15º of flexion. For the distal interphalangeal (DIP) joints of the finger a slight flexion of 10–20º is advised. Some women patients, however, prefer straight fusion. Therefore, one should discuss with the patient the desirable fusion angle before surgery. For the PIP joints, the angle of arthrodesis is increased 5º towards each of the ulnar digits. For example, in the index finger the recommended fusion angle is 30º, in the long finger 35º, in the ring finger 40º and in the little finger 45º. For the MCP of the fingers it is better not to fuse, because the arc of motion of the fingers is initiated at the MCP joint. However, when there is no other choice but to fuse, the preferred angle is 20–30º of flexion in the index finger, with an increasing angle towards the ulnar digits (Fig. 11.2).

Joint surface preparation To achieve uneventful fusion, surface preparation is important to enable snug contact between the bones and appropriate positioning of the joint.

Flat angle Flat angle preparation is easy because it can be achieved with a bone saw to prepare the surface, but it is not so easy to prepare the surface precisely flat at the intended angle.7 This can inherently result in malposition or poor apposi-

149


A

B

FIGURE 11.1 Positions for thumb arthrodesis. A 45º palmar abduction. B 20º radial abduction.

tion. There is a higher risk of non-union than with other types of preparation.

Cup and cone preparation

Carroll8 first reported this method in 1969 (Fig. 11.3), and others have proposed a similar procedure.9 In this method, the distal end of the proximal bone is rounded like a bullet end using a rongeur, and the proximal end of the distal bone is curetted until the concavity is large enough to accommodate the previously prepared cone end.

Chevron-type preparation Chevron osteotomy (Fig. 11.4) is useful to create more contact between the bones and prevent rotation after surgery.10 However, this is not so easy to perform on smaller joints.

METHOD OF FIXATION AND PITFALLS Mechanical properties of fixation methods There are various methods of fixation reported in the literature. Vanik et al.11 compared the strength of internal fixation of Kirschner wires, intraosseous wiring, and plates. They found that intraosseous wiring was stronger than Kwiring, and that right-angle double-loop wiring was the

strongest of the intraosseous configurations. The strength of right-angle loop wiring with 26 gauge wire was comparable to that of dorsal plating. Kovach et al.12 compared strength between methods such as the use of one oblique and one longitudinal K-wire, intraosseous wiring with one oblique K-wire, and tension band wiring. They found that tension band wiring was the strongest in anteroposterior bending and torsion, and that there was no difference in lateral bending between the techniques. Wyrsch et al.13 compared strength of Herbert screws with that of tension band wiring, and found that the Herbert screw had greater anteroposterior and lateral bending strength and torsional rigidity.

Kirschner wiring K-wires are readily available in any operating room and in different diameters. One can choose the most suitable size among them, but for small joints 0.7–1.0 mm wires are preferred in DIP joints, and 1.0 or 1.2 mm in PIP and MP joints. Although many fixation devices are now available, K-wires are preferred because they are cheap, quick and easy to handle and, more than anything else, serve the purpose of fusion when properly used. Usually, two or more wires are used to fuse the joint. Cross-pinning is preferred to parallel pinning because crosspinning is more resistant to separation forces, but it is weak

Arthrodesis Techniques 151

FIGURE 11.4 Chevron-type preparation.

A

B

FIGURE 11.2 Positions for finger arthrodesis: 20–30º of flexion in the index finger, with an increasing angle towards the ulnar digits. FIGURE 11.5 Kirschner wiring for joint fixation. A is weaker than B against rotational torque.

however, double wiring is more sophisticated and difficult, and the combination of oblique K-wiring and single interosseous wiring (Fig. 11.6) is a realistic choice.14 Double wiring requires more extensive exposure than simple K-wiring, so that there is a potential danger of reduced blood circulation to the area.

Tension band wiring

FIGURE 11.3 Cup and cone preparation.

against rotational torque when the crossing point lies just on the joint (Fig. 11.5).

Interosseous wiring Interosseous wiring is used in situations where more solid fixation is needed. Certainly double right-angled interosseous wires are stronger than a single wire.11 In practice,

Compared with interosseous wiring the tension band technique requires only dorsal exposure, and is stronger against anteroposterior bending stress than against lateral bending.12,15 It does not usually require immobilization of the adjacent fingers,16 and has a higher union rate and a lower infection rate than K-wire fixation.17,18 The disadvantage of this technique is that the joint to be fused needs to be flexed, because the ends of the wire need to protrude from the cortex to catch the cerclage wire (Fig. 11.7).

Screw fixation With the invention of various kinds of small interfragmentary screw, such as the Acutrac screw (Acumed) or the Herbert screw,19 screw fixation is an option commonly accepted by many surgeons today. However, when screws

152 Hand and Upper Extremity Reconstruction A

B

C

FIGURE 11.6 Interosseous wiring.

A

B

C

FIGURE 11.7 Tension band wiring.

Smaller, thinner plates are now commercially available for use in small joint arthrodesis. These have the advantage of a shorter period of external splinting and less hardware irritation,20 but plates must be accurately bent to obtain a precise angulation. Unwanted space may be left at the osteotomy site when the plate is applied, which may lead to delayed or non-union.

carpals and carpal bones. It is used for intercarpal arthrodesis of the carpus, and for arthrodesis of the CMC and MP of the thumb, but not for IP finger joints (Fig. 11.9). The staples have reasonable power to withhold the tension side of the fusion, but are not strong enough on the compression side. At least two staples should be applied on the dorsal tension side, placed parallel to each other with the legs of the staples aiming for the center of the tubular bone and the bodies separated by 60–90º around the bone and perpendicular to the bony surface. When the staple becomes loose, there is the potential danger of attenuating the surrounding soft tissue and extensor tendons. In such cases the staples should be removed.

Staple fixation

External fixation

are applied to the digits, the angle cannot be adjusted precisely to the desired position because most screws are inserted intramedullary and the angle of fusion cannot be straight or be more than 45º of flexion (Fig. 11.8A,B).

Plate fixation

Shapiro21 introduced a new device called a bone stapler to put thinner staples into smaller bones, such as the meta-

Smaller external fixators are now available (Fig. 11.10). External fixation has the advantage of compressing the


A

FIGURE 11.9 Carpometacarpal arthrodesis with a K-wire and staples.

B FIGURE 11.8 Arthrodesis with Acutrac screw. A Radiograph showing severe arthritis of the thumb MCP joint. B Arthrodesis with Acutrac screw.

denuded articular surface as well as achieving the subtle angle one desires, but at the same time it has the disadvantage of risk of infection or restricting the motion of the adjacent fingers. The rate of union is reasonably high.22,23

Bone (peg) grafting A bone peg is used as a dowel to adjust and fix the arthrodesis site24 (Fig. 11.11). It is indicated in situations in which the bone substance is lost and extra length of the digit is needed. It can be inserted intramedullary to obtain straight angle fusion, or from the cortex to the medullary cavity to obtain angled fusion. Drawbacks of this method are the difficulty of preparing a bone peg to fit the canal snugly, putting it into the canal, and fixing it at the desired angle. In addition, it requires bone graft from a distant site, which may be bothersome for the patient.

FIGURE 11.10 Arthrodesis with an external fixator.

PROCEDURES IN EACH JOINT Interphalangeal joint arthrodesis Indications and contraindications

Common indications for DIP and PIP joint arthrodesis are joints that have been destroyed by trauma, painful osteoarthritis, and paralytic deformities. The DIP joint arthrodesis is indicated for old flexor profundus injuries that are no

154 Hand and Upper Extremity Reconstruction longer reparable.25 It is also indicated in fingers with Heberden’s nodules that are too painful and unsightly for the patient. PIP or DIP joint arthrodesis is also indicated in fixed flexion contracture after burns, or in unstable joints due to arthritis.26 For severe swan-neck or boutonnière deformity with advanced destruction of the PIP joint due to arthritis, fusion is the only choice. Generally speaking, morbidity from DIP fusion is small but is greater with PIP fusion.

Operative technique The dorsal approach is usually applied to the interphalangeal joint. In the DIP joint, the extensor tendon is step-cut and the collateral ligament cut almost entirely to expose the joint. In the PIP joint, the extensor tendon is divided in the midline and the joint exposed subperiosteally. When a flat cut is made it is easier to cut the head of the middle

phalanx first, and then remove the base of the distal phalanx in the DIP joint. Likewise, with the PIP joint, cut the head of the proximal phalanx first. Further resection may be necessary to adapt the cut surface. It is not always easy to prepare the cut surface at the desired angle. One should be prepared to use a small bone chip graft to fill the opening at the fusion site. Any type of fixation can be chosen. The cross-pinning technique is introduced here. Two oblique 1 mm K-wires are drilled distally from the distal cut surface (Fig. 11.12A) and the joint is positioned at the desired angle (Fig. 11.12B). The wires are drilled in a retrograde fashion until they reach the proximal cortex (Fig. 11.12C), care being taken to keep the joint at the desired angle and not rotated. After confirming solid fixation, the extensor tendon and the skin are closed primarily. Usually hemostasis is necessary before closing the dorsal skin.

Postoperative care For DIP fusion, single-digit splinting with an aluminum splint will suffice. This is continued for about 6–8 weeks. For PIP fusion with K-wires a short arm splint incorporating a neighbor digit is applied for 2 weeks, and then switched to a single-digit aluminum splint, continued for an additional 4–6 weeks until radiological fusion is seen.

Metacarpophalangeal joint arthrodesis Indications and contraindications

Because MP joints play an important role in hand function, they should be preserved as much as possible. MP joint arthroplasty is preferred to arthrodesis in the fingers. For MP joints of the thumb, however, arthrodesis is sometimes indicated, especially in rheumatoid arthritis or in paralytic hand.27 Thumb MP joint instability, pain, or deformity seriously impairs thumb function, and fusion is a good option, provided both IP and CMC joints are intact. Con-

FIGURE 11.11 Arthrodesis with bone peg graft.

A

B

C

FIGURE 11.12 A Two oblique 1-mm K-wires are drilled distally from the distal cut surface. B The joint is positioned at the desired angle and without rotation. C The wires are drilled in a retrograde fashion until they reach the proximal cortex.

Arthrodesis Techniques 155 versely, it is less indicated when the neighbor joints are diseased.

Operative technique The thumb MP joint is approached dorsally between the extensor pollicis longus and brevis tendons. The capsule is excised, and the collateral ligaments are divided as needed. The joint is shaved and prepared for fusion. A ‘cup and cone,’ ‘flat cut’ or ‘chevron cut’ can be used, according to the surgeon’s choice. Methods of fixation are similar to those for interphalangeal joints. When the cup and cone method is employed, the head of the metacarpal is denuded and shaped like a cone using a rongeur. The cup is prepared with multiple awl holes created at the base of the proximal phalanx. These holes are connected with a small osteotome, and the cartilage is removed from the area. With a curette, the hole is enlarged until it fits snugly with the cone. Two 1.2-mm diameter K-wires are then drilled through the cup and the joint is held in the desired position. The well-contoured cup and cone ends are approximated, and the wire is drilled back in a retrograde fashion.

Postoperative care When a rigid fixation such as an interfragmentary screw is used, the MP joint is immobilized in an aluminum splint for 2–3 weeks. When K-wires are used, it should be immobilized in a thumb spica splint for the first 2 weeks, followed by an aluminum splint for 4 weeks.

Carpometacarpal joint arthrodesis Indications and contraindications

Degenerative change is frequently seen in the CMC joint of the thumb. Its treatment includes ligamentoplasty, simple excision arthroplasty of the trapezium, anchovy arthroplasty, and implant arthroplasty. None of these can withstand strong pinch nor grasp after surgery. Fusion is indicated when grasping power is of prime importance. However, the thumb will remain stiff for a couple of years after the fusion, and the patient may complain of clumsiness when using the hand. Gradually the thumb motion is compensated by the MP joint and the scaphotrapezial joint.28 The best indication for the arthrodesis of the thumb CMC is in manual workers who require a strong grip. It is contraindicated in the presence of osteoarthritis in either the MP or the scaphotrapezial joint.29 If the thumb shows severe swan-neck deformity, i.e. hyperextension of the MP joint, and adduction contracture of the metacarpal, volar plate advancement of the MP joint and release of the adduction contracture should be performed as well.

Operative technique The most frequently fused CMC joint is in the thumb. Non-union in this joint is relatively common30 because of its configuration: it is a saddle joint, which makes complete decortication of the joint surface difficult when minimal resection is performed. In order to prepare the flat cut surface, one needs to cut well away from the cartilage.

Positioning the metacarpal and the trapezium at the desired angle and coaptation of the cut surfaces is rather difficult. The author recommends the use of an interpositional iliac bone graft that is not too thick. Carroll 28 recommended the technique of cup and cone arthrodesis instead of bone grafting. In the CMC joint, the cup is made on the trapezium and the cone on the metacarpal. A 3 cm longitudinal skin incision is made on the dorsal aspect of the CMC joint. Sensory branches of the radial nerve are identified and protected, as injury to them will cause uncomfortable paresthesia or painful neuroma after surgery. The joint is approached between the extensors pollicis longus and brevis, exposed subperiosteally, and two parallel cuts centering on the joint are made to denude it. Because of the shape of the joint, the thickness of the bone to be removed is about 3–4 mm on each side. Preparation of the surface side is easy, but the deep concavity is rather difficult. The thumb is pulled and held at an angle of 45º palmar abduction and 20–30º radial abduction (Fig. 11.1). A piece of iliac bone graft is prepared to fit the space created by the excision, varying in thickness between 3 and 7 mm according to the size of the cavity. Two or three 1.5 mm K-wires are used to fix the joint. If staples are available, pinning with an oblique K-wire and two staples on the dorsal side at an angle of 90º will enhance stability (Fig. 11.9). One may use interfragmentary screws to compress the fusion site,31 but must be aware that such screws do not guarantee union.30 While this being done, attention must be paid to the position of the CMC joint, which should be held open and the thumb tip should oppose the index tip, otherwise a narrower thumb index angle (adducted thumb) can be problematic.

Postoperative care A thumb spica cast is used for 6 weeks, followed by 2 weeks in a removable splint. After clinical and radiological union is confirmed, the splint is removed. If questionable union is suspected, splinting should be continued until union is confirmed radiologically. The K-wires and staples can be removed after 3 months.

Outcomes Painfree arthrodesis is expected from this procedure. However, some patients may complain of clumsiness and stiffness a couple of years after the surgery, which may resolve eventually.28 A small number of cases can subsequently develop scaphotrapezial joint osteoarthritis.

Limited wrist arthrodesis Limited wrist fusion is intended to eliminate pain and instability of the affected intercarpal joint while maintaining reasonable wrist mobility. It is indicated when the pathology is limited to certain areas of the wrist joint, and contraindicated when the entire wrist joint is affected. In the latter case total wrist arthrodesis is the procedure of choice. There are about a dozen limited wrist fusion procedures, several well accepted types of which are discussed here.


STT fusion

Indications and contraindications Scaphotrapeziotrapezoid (STT) fusion was popularized by Watson.32 It fuses the scaphoid with the trapezium and the trapezoid, thereby stabilizing the radial column of the wrist, and corrects the rotated scaphoid to its normal position. It is therefore indicated in chronic rotary subluxation of the scaphoid33 and treats osteoarthritis of the STT joint.32 It alters the transmission of load through the radial column, so that it unloads the lunate. Therefore, it is indicated for Kienbock’s disease of Lichtman stage 3A or B.34,35 Although there are favorable long-term reports, poor results have also been reported.36,37 Precise performance of the technique is of supreme importance, but the patient should be informed of loss of certain wrist motion and possible persistent pain.35 The procedure is contraindicated if there is preexisting osteoarthritis at the radioscaphoid joint.

Operative technique The STT joint is approached dorsoradially via a 4-cm transverse incision just distal to the radiocarpal joint. The extensor retinaculum is opened along the extensor pollicis longus. The STT joint is opened transversely through the transverse incision between the extensors carpi radialis longus and brevis. The cartilage and subchondral bones between the trapezium and the trapezoid and the scaphoid are removed with an osteotome and a rongeur. The volar lip of the distal scaphoid is removed by elevating the trapezium and the trapezoid distally. After cartilage excision, two or three K-wires are preset from the dorsal trapezium and trapezoid to the STT joint surface. A 3–5 mm thick spacer is placed into the STT joint to hold the original contour. The operator’s thumb is then pushed against the distal tuberosity of the scaphoid, the wrist being placed in full radial deviation and 45º of dorsiflexion. The preset wires are driven proximally into the scaphoid body. Care must be taken that the wires are not driven into the radioscaphoid joint. Under fluoroscopy the radioscaphoid angle is checked to be approximately 55–60º on the lateral view. Watson38 warns that scaphoid flexion should not be overcorrected in an attempt to unload the lunate. Cancellous bone chips from the iliac crest are harvested and densely packed in the space created between the scaphoid and the trapezium and trapezoid. The wires are cut underneath the skin, and the capsule and the skin closed primarily. A short arm thumb spica cast is applied with the wrist in neutral.

Postoperative care Usually, the cast is discontinued after 6–8 weeks. X-rays are taken to confirm radiological union. When in doubt, one should continue immobilization for a couple more weeks. When wearing the cast, patients are encouraged to move the fingers fully to avoid contracture. The pins are removed after 12 weeks when radiological union is complete.

Outcomes The expected arc of motion is 80% and grip power is 77% of that of the contralateral normal wrist.33 The possibility

of long-term development of osteoarthritis around the STT joint is yet to be determined.35 Rogers39 reported impingement between the radial styloid and the scaphoid and modified the procedure to include a radial styloidectomy at the time of surgery to prevent this. Minami40 reported the occurrence of osteoarthritis in the radioscaphoid joint in 23% of patients.

Four-corner fusion

Indications and contraindications

Watson and Ballet41 first reported fusion of the capitate, the hamate, the lunate and the triquetrum to treat SLAC wrist (Fig. 11.13A). This operation has expanded to treat scaphoid necrosis advanced collapse (SNAC) wrist and midcarpal instability.42 It is contraindicated when there is pre-existing osteoarthritic change in the radiolunate joint or osteonecrosis of the lunate.

Operative technique A longitudinal skin incision is made on the dorsal wrist and the extensor retinaculum opened in a zigzag fashion along the fourth dorsal compartment. The extensor tendons are retracted radially or ulnarly as needed. The dorsal capsule is opened transversely at the level of the capitolunate joint. Radially, the scaphoid is exposed and removed in piecemeal fashion with a rongeur. Centrally, the lunate is elevated to confirm that the radiolunate joint is well preserved. Then, cartilage and subchondral bones are removed from the intercarpal joints between the capitate, hamate, triquetrum, and the lunate using a rongeur and an osteotome. The volar joint space between the capitate and the lunate is difficult to denude, and so the wrist is pulled and flexed to expose the joint for that purpose. In the space thus created cancellous bone is packed, donated from either the distal radius or the iliac bone. If the lunate is dorsally tilted a K-wire is temporarily inserted into the lunate and lifted distally to correct its posture and keep it in the neutral position. If the capitate has migrated radially and proximally, as is often seen in advanced collapse, it should be reduced into normal alignment. 1.5 mm K-wires are then inserted percutaneously from the capitate, the hamate, and the triquetrum to the lunate, and from the triquetrum to the capitate (Fig. 11.13B), and then cut short under the skin. Instead of Kwires, which can irritate the skin, one can use a Herbert screw, staples, or a circular plate with six to eight holes,43 but one should be aware that the circular plate has more frequent complications (e.g., non-union or hardware irritation) than conventional plates.44,45 The wrist is immobilized in a short arm cast in the neutral position.

Postoperative care The cast is worn for 6–8 weeks postoperatively until radiologic union is confirmed. While the cast is in place patients are encouraged to move the fingers fully to avoid contracture. The pins are removed after 12 weeks when radiologic union is complete. However, if any of the pins are catching on the extensor tendons, one should not hesitate to remove them.


Radiolunate fusion

Indications and contraindications This limited fusion provides good pain relief and range of motion. The indications for radiolunate fusion are degenerative change of the lunate fossa in the radius after die punch fracture and in Kienbock’s disease. It is also indicated to prevent ulnar translation of the carpus in rheumatoid wrists.46 It is also performed to treat volar intercalated segmental instability, ulnar translation of the carpus (Fig. 11.14A) and dynamic midcarpal instability.47 The presence of degenerative change in the capitolunate joint is a contraindication because this midcarpal joint will bear the load and motion of the wrist after radiolunate fusion.

Operative technique

A

A longitudinal incision is made on the dorsal wrist and the extensor retinaculum is opened in a zigzag fashion. The extensor tendons in the fourth compartment are retracted with a tape. The posterior interosseus nerve is coagulated to reduce postoperative pain. The dorsal capsule is opened transversely at the radiocarpal joint. The proximal surface of the lunate and fossa lunatum are decorticated with rongeurs. A single bone block graft is prepared from either the iliac crest or the radial styloid, or from the ulnar head when Darrach’s procedure is combined. It is inserted between the lunate and the lunate fossa, after adjusting the lunate into a neutral position. Two parallel K-wires are inserted distally from the radial aspect of the radius, piercing through the lunate fossa to the lunate. Alternatively, a staple can be used (Fig. 11.14B). The height of the lunate should be maintained to unload the scaphoid. Fluoroscopy is used to check that the wires do not penetrate the midcarpal joint, and that the lunate is in normal alignment. Cancellous bone chips are packed into the residual space between the lunate and the radius. The wound is closed in layers.

Postoperative care The arm is immobilized in a long arm cast for 2 weeks, followed by 6 weeks in a short arm cast. After 8 weeks, when radiologic union is confirmed, the wires are removed. During immobilization the patient is encouraged to move the fingers to avoid contractures.

Outcomes The postoperative arc of motion is 80% of that of the contralateral wrist. Pain relief is quite acceptable.

B FIGURE 11.13 A Preoperative radiograph. B Postoperative radiograph showing the four-corner fusion.

Outcomes The expected range of motion is 50–60% and grip power is 80% of that of the contralateral wrist.45 So far, no increased occurrence of radiolunate osteoarthritis has been reported.

Total wrist arthrodesis

Indications and contraindications Total wrist arthrodesis has been a reliable procedure to stabilize the wrist joint and relieve pain. It is indicated in wrists with destruction of both the radiocarpal and midcarpal joints due to trauma, arthritis, tumor, or infection. It is also indicated after failed total wrist arthroplasty or proximal row carpectomy. It is also used to treat paralytic or spastic wrist deformities. Wrist flexion deformity due to spastic-type cerebral palsy can be corrected with wrist


A

B

FIGURE 11.14 A Preoperative radiograph. B Radiograph showing screw between the lunate and the radius.

arthrodesis, which helps to improve hygiene and appearance.48 Contraindications are young people whose epiphysis are still open, and wrists in which either the radiocarpal or the midcarpal joint is intact. Such wrists can be treated with limited fusion. It is also contraindicated in quadriplegic patients who require active wrist motion when performing grasp and pinch after tendon transfer.

Operative technique

Non-rheumatoid wrist A longitudinal incision is made on the dorsum of the wrist, centered over Lister’s tubercle. The distal end of the incision is between the index and long metacarpals and the proximal incision ends at the muscle belly of the abductor pollicis longus. Care should be taken not to damage the sensory branches of the radial nerve. The third compartment is opened and the EPL is mobilized, transposed radially with a tape. The distal radius is exposed subperiosteally, the dorsal capsule is incised longitudinally, and the carpal bones are exposed. When exposing the distal radius it is wise not to enter the fourth or the second compartment, but rather to elevate the two subperiosteally to avoid irritating the tendons. All the cartilage of the carpal bones in the radiocarpal and the midcarpal joints is decorticated. The

joints in the ulnar column, such as the lunotriquetral, lunohamate, and capitohamate, do not necessarily have to be prepared because they allow little transverse movement. Small bone chips packed into the fusion site are harvested from either the radial styloid, the olecranon, or the iliac crest, depending on the amount and quality of bone graft required. One can use the excised ulnar head if Darrach’s procedure is performed at the same time. When K-wires are used, bone chips are scattered evenly in the radiocarpal and midcarpal spaces. The wrist is held in the desired position of fusion. Two parallel wires 1.8 or 2.0 mm in diameter are inserted obliquely from the proximal radial side of the radial styloid distal–ulnarwards to fix the radius to the scaphoid and the lunate, then the scaphoid and the lunate to the capitate. Another wire is then inserted from the radial side of the second metacarpal base towards the capitate to the distal radius through the lunate (Fig. 11.15). When a stronger plate, such as a low-contact dynamic compression plate (LC-DCP) from the AO group is to be used, Lister’s tubercle and the dorsal prominence of the cortex are removed to obtain a flat surface to accommodate the plate. The LC-DCP plate includes the middle finger CMC joint in the fusion; this joint is also decorticated and prepared. Special attention is required when


FIGURE 11.15 Total wrist fusion with K-wires.

FIGURE 11.16 Total wrist fusion with a plate.

placing the distal three screws, as these determine the rotation and angulation of the fusion itself (Fig. 11.16). A Penrose drain is left in the wound. The retained capsule is repaired, including the periosteum of the radius in the closure. The EPL tendon is left transposed radially on the extensor reticulum to avoid contact with the plate.

styloid to the capitate, and another crosses over the radiolunate joint from the sigmoid notch to the capitate. If a Steinman pin is to be used, the medullary canal of the radius is prepared with an awl. The Steinman pin is inserted through the carpus between the index and middle finger metacarpals and tapped retrogradely into the channel of the radius; the pointed end is then cut to adjust the length of the pin. It is then countersunk 2 cm proximal to the MP joint level. Bone chips are packed into the radiocarpal joint space. Staples4 and oblique K-wires are used to supplement the fixation. Instead of one Steinman pin, two thinner Steinman pins can be used.26

Rheumatoid wrist In the rheumatoid wrist, total wrist arthrodesis is performed in combination with synovectomy and is indicated when the wrist is very unstable or volarly dislocated, with severe destruction of the radiocarpal and intercarpal joints. If the midcarpal joint is relatively intact, radiolunate fusion46 should be chosen, as it leaves some wrist movement. As the skin in rheumatoid arthritis is usually weak, large hardware such as the LC-DCP plate is not recommended. Instead, an intramedullary rod (Steinman pin) or K-wire is preferred. After excising the distal ulna and completing wrist synovectomy, the surgeon removes the carpal bone cortices of the radiocarpal and midcarpal joints. If the carpus tends to fall volarly, the dorsal part of the radial styloid should be removed to fit the remaining carpus.49 In cases where the carpal bones are almost gone, iliac corticocancellous bone graft3 is occasionally indicated to supplement the carpal height. The excised ulnar head can be used as a graft. Two K-wires cross over the radioscaphoid joint from the radial

Postoperative care When the LC-DCP is used an external splint is usually not necessary, but its use is recommended to reduce swelling and pain in the acute postoperative days. When K-wires are used, a short arm splint followed by a cast is necessary for approximately 8 weeks. While the wrist is immobilized, the patient is encouraged to actively move the fingers fully.

Outcomes Pain relief is gratifying, but wrist stiffness is bothersome for a while. An increased incidence of CMC osteoarthritis following total wrist fusion has been reported.50 When the DCP is used, extensor tendonitis can be a problem.51


COMPLICATIONS Wound problems If the skin is closed under undue tension the wound might develop marginal necrosis or secondary infection as a result of avascularity. This occurs when too large a plate is applied at the metacarpal. ● Infection When K-wire fixation is employed, one tends to leave the end of the wires exposed above the skin. This can be a cause of pin tract infection. The exposed wires or pins should be cleaned meticulously. Once the pins are infected, it is better to remove them as soon as possible. ● Malunion Malposition of the joint to be fused will inevitably lead to malunion and should be corrected at the time of surgery. Even after surgery, fixations with K-wires are weak enough to allow unwanted rotation or angulation. ● Non-union As in other major joints, non-union in small joints is always a complication that should be anticipated. When there is poor blood supply or poor sensation, the risk of non-union is high. Technically, poor apposition, inadequate removal of the joint surface and improper fixation are the major causes. Cancellous bone graft might help, but not always. ● Stiffness of the adjacent joints When immobilization includes adjacent joints and is continued over weeks, elderly patients are likely to develop stiffness of the adjacent joints. This is certainly an unwanted complication and the patients suffer greater morbidity than from the fusion itself. Contracture of adjacent joints should be prevented by all means. For this reason external splinting must be minimal and sufficiently short, and motion of the adjacent joints should be initiated early.

CONCLUSIONS The procedures of common arthrodesis procedures for the hand are described. Use of the appropriate indications and techniques will maximize the patient’s benefit from the procedure. Small joint and wrist arthrodesis will remain a reasonable option for painful, unstable, and destroyed joints.

REFERENCES 1. Hobby JL, Lyall HA, Meggitt BF. First metacarpal osteotomy for trapeziometacarpal osteoarthritis. J Bone Joint Surg [Br] 1998; 80: 508–512. 2. Weiss AC, Wiedeman G Jr, Quenzer D, et al. Upper extremity function after wrist arthrodesis. J Hand Surg Am 1995; 20: 813–817. 3. Carroll RE, Dick HM. Arthrodesis of the wrist for rheumatoid arthritis. J Bone Joint Surg [Am] 1971; 53: 1365–1369. 4. Clayton M, Ferlic D. Arthrodesis of the arthritic wrist. Clin Orthop 1984; 187: 89–93. 5. Haddad RJ, Riordan D. Arthrodesis of the wrist. J Bone Joint Surg 1967; 49A: 950–954. 6. Millender L, Nalebuff E. Arthrodesis of the rheumatoid wrist. J Bone Joint Surg 1973; 55A: 1026–1034. 7. Burton RI, Margles SW, Lunseth PA. Small-joint arthrodesis in the hand. J Hand Surg Am 1986; 11: 678–682.

8. Carroll RE, Hill NA. Small joint arthrodesis in hand reconstruction. J Bone Joint Surg [Am] 1969; 51: 1219–1221. 9. McGlynn JT, Smith RA, Bogumill GP. Arthrodesis of small joint of the hand: a rapid and effective technique. J Hand Surg Am 1988; 13: 595–599. 10. Pribyl CR, Omer GE, McGinty L. Effectiveness of the chevron arthrodesis in small joints of the hand. J Hand Surg Am 1996; 21: 1052–1058. 11.Vanik RK, Weber RC, Matloub HS, et al. The comparative strengths of internal fixation techniques. J Hand Surg Am 1984; 9: 216–221. 12. Kovach JC, Werner FW, Palmer AK, et al. Biomechanical analysis of internal fixation techniques for proximal interphalangeal joint arthrodesis. J Hand Surg Am 1986; 11: 562–526. 13. Wyrsch B, Dawson J, Aufranc S, et al. Distal interphalangeal joint arthrodesis comparing tension-band wire and Herbert screw: a biomechanical and dimensional analysis. J Hand Surg Am 1996; 21: 438–443. 14. Lister G. Intraosseous wiring of the digital skeleton. J Hand Surg Am 1978; 3: 427–435. 15. Mittelmeier W, Lehner S, Gollwitzer H, et al. Comparing biomechanical investigations about different wiring techniques of finger joint arthrodesis. Arch Orthop Trauma Surg 2005; 125: 145–152. 16. Allende BT, Engelem JC. Tension-band arthrodesis in the finger joints. J Hand Surg Am 1980; 5: 269–271. 17. I. Jsselstein C, van Egmond DB, Hovius SE, van der Meulen JC. Results of small-joint arthrodesis: comparison of Kirschner wire fixation with tension band wire technique. J Hand Surg Am 1992; 17: 952–956. 18. Uhl RL, Schneider LH. Tension band arthrodesis of finger joints: a retrospective review of 76 consecutive cases. J Hand Surg Am 1992; 17: 518–522. 19. Leibovic SJ, Strickland JW. Arthrodesis of the proximal interphalangeal joint of the finger: comparison of the use of the Herbert screw with other fixation methods. J Hand Surg Am 1994; 19: 181–188. 20. Buchler U, Aiken MA. Arthrodesis of the proximal interphalangeal joint by solid bone grafting and plate fixation in extensive injuries to the dorsal aspect of the finger. J Hand Surg Am 1988; 13: 589–594. 21. Shapiro JS. Power staple fixation in hand and wrist surgery: new applications of an old fixation device. J Hand Surg Am 1987; 12: 218–227. 22. Bishop AT. Small joint arthrodesis. Hand Clin 1993; 9: 683–689. 23. Leonard MH, Capen DA. Compression arthrodesis of finger joints. Clin Orthop Rel Res 1979; 145: 193–198. 24. Moberg E, Henrikson B. Technique for digital arthrodesis. A study of 150 cases. Acta Chir Scand 1960; 118: 331–338. 25. Schneider LH. Flexor tendons – late reconstruction, In: Green’s Operative Hand Surgery, 4th ed. Philadelphia: Churchill Livingstone, 1999. 26. Feldon P, Terrono A, Nallebuff E, Millender L. Rheumatoid arthritis and other connective tissue diseases, In: Green’s Operative Hand Surgery, 4th edn. Philadelphia: Churchill Livingstone, 1999. 27. Hastings H 2nd, Davidson S. Tendon transfers for ulnar nerve palsy. Evaluation of results and practical treatment considerations. Hand Clin 1988; 4: 167–178. 28. Carroll RE, Hill NA. Arthrodesis of the carpo-metacarpal joint of the thumb – A clinical and cinerentogenographic study. J Bone Joint Surg [Br] 1973; 55: 292–294. 29. Stark HH, Moore JF, Ashworth CR, Boyes JH. Fusion of the first metacarpotrapezial joint for degenerative arthritis. J Bone Joint Surg [Am] 1977; 59: 22–26. 30. Clough DA, Crouch CC, Bennett JB. Failure of trapeziometacarpal arthrodesis with use of the Herbert screw and limited immobilization. J Hand Surg Am 1990; 15: 706–711. 31. Pardini AG, Lazaroni AP, Tavares KE. Compression arthrodesis of the carpometacarpal joint of the thumb. Hand 1982; 14: 291–294. 32. Watson HK, Hempton RF. Limited wrist arthrodeses. I. The triscaphoid joint. J Hand Surg Am 1980; 5: 320–327. 33. Wollstein R, Watson HK. Scaphotrapeziotrapezoid arthrodesis for arthritis. Hand Clin 2005; 21: 539–543, vi.

Arthrodesis Techniques 161 34. Watson HK, Ryu J, DiBella A. An approach to Kienbock’s disease: triscaphe arthrodesis. J Hand Surg Am 1985; 10: 179–187. 35. Meier R, van Griensven M, Krimmer H. Scaphotrapeziotrapezoid (STT)-arthrodesis in Kienbock’s disease. J Hand Surg [Br] 2004; 29: 580–584. 36. Van den Dungen S, Dury M, Foucher G, et al. Conservative treatment versus scaphotrapeziotrapezoid arthrodesis for Kienbock’s disease. A retrospective study. Chir Main 2006; 25: 141–145. 37. Ishida O, Tsai TM. Complications and results of scapho-trapeziotrapezoid arthrodesis. Clin Orthop Rel Res 1993; 287: 125–130. 38. Watson HK, Wollstein R, Joseph E, et al. Scaphotrapeziotrapezoid arthrodesis: a follow-up study. J Hand Surg Am 2003; 28: 397–404. 39. Rogers WD, Watson HK. Radial styloid impingement after triscaphe arthrodesis. J Hand Surg Am 1989; 14: 297–301. 40. Minami A, Kato H, Suenaga N, Iwasaki N. Scaphotrapeziotrapezoid fusion: long-term follow-up study. J Orthop Sci 2003; 8: 319–322. 41. Watson HK, Ballet FL. The SLAC wrist: scapholunate advanced collapse pattern of degenerative arthritis. J Hand Surg Am 1984; 9: 358–365. 42. Lichtman DM, Bruckner JD, Culp RW, Alexander CE. Palmar midcarpal instability: results of surgical reconstruction. J Hand Surg Am 1993; 18: 307–315. 43. Enna M, Hoepfner P, Weiss AP. Scaphoid excision with fourcorner fusion. Hand Clin 2005; 21: 531–538.

44. Chung KC, Watt AJ, Kotsis SV. A prospective outcomes study of four-corner wrist arthrodesis using a circular limited wrist fusion plate for stage II scapholunate advanced collapse wrist deformity. Plast Reconstruct Surg 2006; 118: 433–442. 45. Vance MC, Hernandez JD, Didonna ML, Stern PJ. Complications and outcome of four-corner arthrodesis: circular plate fixation versus traditional techniques. J Hand Surg Am 2005; 30: 1122–1127. 46. Chamay AG. Radiolunate arthrodesis in the rheumatoid wrist. J Hand Surg Am 1986; 11: 771. 47. Halikis MN, Colello-Abraham K, Taleisnik J. Radiolunate fusion. The forgotten partial arthrodesis. Clin Orthop Rel Res 1997; 341: 30–35. 48. Rayan GM, Young BT. Arthrodesis of the spastic wrist. J Hand Surg Am 1999; 24: 944–952. 49. Albright J, Chase R. Palmar-shelf arthroplasty of the wrist in rheumatoid arthritis. J Bone Joint Surg 1970; 52A: 896–906. 50. Belt EA, Kaarela K, Kautiainen HJ, et al. Does wrist fusion cause destruction of the first carpometacarpal joint in rheumatoid arthritis? 18 patients followed for 2–6 years. Acta Orthop Scand 1997; 68: 352–354. 51. Weiss AP, Hastings H 2nd. Wrist arthrodesis for traumatic conditions: a study of plate and local bone graft application. J Hand Surg Am 1995; 20: 50–56.

CHAPTER

Arthroplasty Procedures in the Hand

12

Erika Davis Sears and Kevin C. Chung

INTRODUCTION Post-traumatic arthritis, degenerative arthritis, rheumatoid arthritis and other connective tissue diseases affect finger joint motion and interfere with the ability to use the hand in everyday activities. For patients with severe disease that fails to respond to non-operative treatment, arthrodesis or arthroplasty are acceptable options. Arthrodesis offers predictable pain relief at the cost of loss of motion. Arthroplasty preserves motion, but the amount of motion is not ideal. Complications such as implant failure and joint instability may arise after arthroplasty and hamper hand function. In counseling patients about treatment options the surgeon must have a thorough understanding of joint mechanics and the underlying disease process affecting the patient. The disease process may be isolated to a single joint, as is usually the case in post-traumatic arthritis, or may affect several joints at the same time, as in the case of rheumatoid arthritis. Reduced function of the index finger joints affects pinch, whereas abnormal function of the joints of ulnar digits results in impaired power grip. When joints of the thumb are diseased, both pinch and grip strength are affected.

OSTEOARTHRITIS (OA) VERSUS RHEUMATOID ARTHRITIS (RA) Osteoarthritis typically affects the basal joint of thumb, proximal interphalangeal (PIP), and distal interphalangeal (DIP) joints of the fingers (Fig. 12.1). The DIP joint is most frequently involved, and fusion is a predictable operation to alleviate pain and enhance the appearance of the finger. The DIP joint needs stability, and the loss of motion after fusion is not problematic. The thumb carpometacarpal (CMC) joint is the next most commonly involved joint, followed by the PIP joints. Osteoarthritis in both CMC and PIP joints can cause severe functional impairment. With thumb

basal joint arthritis, long-term ligament laxity, whether idiopathic or post-traumatic, is postulated to be the etiologic factor. The trapeziometacarpal (TMC) joint is usually affected in thumb basal joint arthritis, which may also be accompanied by scaphotrapezial joint disease. OA rarely involves the metacarpophalangeal (MCP) joint, but in RA the MCP joints are commonly affected. Rheumatoid arthritis is a disorder that results in proliferation of synovial tissue, which can afflict any joint. The abnormal synovial hypertrophy results in destruction of articular cartilage and subchondral bone. The surrounding soft tissues, including tendons and ligaments that support the involved joint, become stretched and cause joint imbalance. The synovial tissue may invade flexor and extensor tendons, resulting in tendon rupture. Although RA may affect any joint, the MCP and PIP joints of the hand are affected early, with the MCP joint being the most commonly affected joint in the hand. Patients with RA develop ulnar deviation and volar subluxation at the MCP joints (Fig. 12.2). This common deformity can be the result of one or more of the following deforming forces: carpal collapse causes radial deviation of the metacarpals and compensatory ulnar deviation of the proximal phalanges; attenuation or stretching of the radial sagittal bands allows ulnar and volar subluxation of the extensor mechanism; and unbalanced interosseous and flexor tendon forces from the subluxed extensor tendons cause further flexion deformity at the MCP joints. Initially, patients retain passive movement at the MCP joints. However, when the deformities become fixed, the patient is unable to open the hand to grasp objects. Patients with flexion and ulnar deviation at the MCP joints often have other deformities of the PIP and DIP joints. Dorsal subluxation of the lateral bands, laxity of the volar plate at the PIP joint, and rupture of the distal insertion of the extensor mechanism result in swan-neck deformity (Fig. 12.3A,B), or hyperextension of the PIP joint and flexion at the DIP joint. Patients may have boutonnière

163


A FIGURE 12.3 A Photograph of swan-neck deformity. FIGURE 12.1 Bilateral CMC osteoarthritis, with mild DIP and PIP osteoarthritis.

deformity in other fingers (Fig. 12.4A,B), which is characterized by a flexed posture at the PIP joint and hyperextension at the DIP joint. This deformity is caused by persistent PIP joint synovitis, leading to attenuation of the central slip and volar subluxation of the lateral bands. Other connective tissue disorders, such as scleroderma, psoriatic arthritis, and systemic lupus erythematosus, may also have erosion of bone and cartilage, inflammation of soft tissues, and abnormal joint function in the hand.

and stability are more important than motion. The thumb MCP joint should be fused to maintain stability during pinch. The only exception is when the thumb IP and MCP joints are both destroyed. Fusing both joints can cause a stiff thumb that may hinder pinch. Therefore, the IP joint should be fused and the MCP joint of the thumb should have the arthroplasty procedure. Which joints should not be fused? The MCP joints of the fingers should not be fused, unless arthroplasty is technically not possible. Finger motion is initiated at the MCP joint first, and fusion of the MCP joint will cause great functional impairment by limiting the ability of the fingers to curl around objects. The thumb CMC joint typically should not be fused because most of the mobility of the thumb arises from this joint. Occasionally, the thumb CMC joint may be fused in manual workers engaged in heavy labor because of the anticipated wear on the arthroplasty procedure. Fusion versus arthroplasty in the PIP joints depends on the digit involved. In general, the PIP joints of the index and middle fingers should be fused because of their participation in pinch. Pinch causes lateral stress and wear at the PIP joint that may lead to implant failure. However, more patients are demanding arthroplasty procedures of the index and middle fingers because of the advancement in implant technology. The ring and little finger PIP joints should have arthroplasty procedures because these joints are important in power grip. Thus, preservation of joint mobility is necessary.

ARTHRODESIS VERSUS ARTHROPLASTY

Arthroplasty options

Arthrodesis is a predictable procedure and should be considered for patients presenting with painful destruction of the hand joints. The question is which joints should undergo arthrodesis and which should undergo arthroplasty? The DIP joints should be fused because pain relief

Numerous arthroplasty procedures in the hand have evolved over time. Thumb CMC, MCP and PIP finger joint arthroplasty account for the majority of arthroplasty procedures performed in the hand today. The choice of technique varies by surgeon preference, underlying disease, and the digit and

FIGURE 12.2 Ulnar deviation and volar subluxation at the MCP joints in the rheumatoid hand.

Arthroplasty Procedures in the Hand 165

A

B FIGURE 12.3, cont’d B X-ray showing swan-neck deformity.

joint involved. Pyrolytic carbon or pyrocarbon implant arthroplasty is a relatively new technique that is increasingly being used in the reconstruction of MCP and PIP joints (Ascension Orthopedics, Inc., Austin, TX) (Figs 12.5, 12.6). Pyrolytic carbon is a synthetic material that is deposited as a coating on graphite substrates by heating a hydrocarbon gas. Pyrocarbon is biocompatible and durable with excellent wear characteristics, which is verified by more than 10 million patient-years of experience with the use of the material as a component of artificial heart valves.1 Pyrocarbon implants are unlinked, minimally constrained,

B FIGURE 12.4 A Photograph of boutonnière deformity. B X-ray showing boutonnière deformity.

and are designed to resemble the anatomic surfaces of joints. Their use requires minimal bone resection, which allows the preservation of the collateral ligaments for joint stabilization. Long-term results on a large number of patients are not yet available.


FIGURE 12.5 MCP pyrocarbon joint implant (drawing from Ascension Orthopedics, Inc., Austin, TX).

FIGURE 12.6 PIP pyrocarbon joint implant (drawing from Ascension Orthopedics, Inc., Austin, TX).

Silicone arthroplasty remains the most widely used and studied implant for MCP and PIP joint abnormalities (Fig. 12.7). The Swanson silicone implants (Wright Medical Technology, Inc., Arlington, TN) have been in use for more than 40 years. Many different designs of silicone implants have been proposed and studied; however, the Swanson remains the preferred choice because of its reported relative flexibility and durability, and the inability of newer silicone implant designs to establish superiority over the Swanson. The Swanson implant does not attempt to reconstruct the joint anatomically; rather, it serves as a dynamic spacer to maintain stability and alignment after resection of the diseased joint. During healing, the body forms a fibrous capsule around the implant that functions to maintain joint stability, even if the implant is fractured. The Swanson MCP and PIP implants are flexible not only to allow flexion and extension, but also to permit added motion in radial and ulnar planes. The ability of the implant to glide or piston within the medullary canal is thought to disperse the forces generated along the implant–bone interface, which preserves the integrity of the surrounding bone and enhances the durability of the implant. Swanson silicone implants have also been devised for thumb CMC arthroplasty, but the high fracture rate associated with the stresses on this joint makes this design an unreliable choice. Today, trapeziectomy with tendon interposition or suspension is the most commonly performed arthroplasty procedure for disease of the thumb CMC joint. The use of tendon for interposition or suspension allows reliable joint reconstruction without subjecting the patient to complications that are inherent with the implantation of foreign material. Although the DIP joint is the most commonly affected joint in OA of the hand, DIP arthroplasty is not performed for treatment of DIP joint abnormalities. Joint debride-

FIGURE 12.7 X-ray showing the Swanson implant.

ment, excision of mucous cysts, and arthrodesis if necessary are the mainstay of surgical treatment for the patient with DIP joint disease. Usually failure of non-surgical treatment and pain interfering with hand function are indications for operative intervention, the goal of treatment being pain relief and not restoration of joint motion. This chapter will highlight important considerations in arthroplasty for disease in the thumb CMC and finger MCP and PIP joints. Indications and contraindications, preoperative considerations, procedural descriptions, and complications for the preferred surgical techniques used in the treatment of each joint by the senior author (KCC) will be discussed.

THUMB CMC ARTHROPLASTY Osteoarthritis, common in middle-aged and postmenopausal women, frequently causes severe impairment at the basal joint of the thumb. Inflammatory arthritides may also produce abnormalities of the thumb basal joint. The severity of disease at the CMC joint is typically described by the Eaton classification system.2 ● Stage I: Articular contours are normal. TMC joint space may be widened. This stage precedes cartilage degeneration.

Arthroplasty Procedures in the Hand 167 Stage II: There is slight narrowing of the TMC joint, but articular contours appear normal. Joint osteophyte when present is 2 mm. The scaphotrapezial joint space appears normal. ● Stage IV: There are degenerative changes in the scaphotrapezial joint surface, in addition to degeneration of the TMC joint. The goal of arthroplasty in the treatment of thumb CMC arthritis is to relieve pain, stabilize the thumb basal joint, restore strength, and improve or preserve mobility. Numerous arthroplasty techniques for thumb CMC arthritis have been described in the literature. Trapeziectomy alone or trapeziectomy combined with silicone arthroplasty, soft tissue interposition, ligament reconstruction, or suspension arthroplasty are among the many options for treatment of advanced thumb CMC arthritis. Complications with silicone arthroplasty, such as joint subluxation, implant failure, and foreign body reaction requiring implant removal, have made arthroplasty with the use of biologic material the preferred option. Partial or complete slips of tendons – flexor carpi radialis (FCR), palmaris longus (PL), or abductor pollicis longus (APL) – are used to interpose or suspend the thumb metacarpal to prevent shortening of the thumb ray after trapeziectomy. FCR tendon reconstruction is the most popular technique used today. Many of the procedures described in the literature achieve reliable pain relief, improve function, and are associated with a high rate of satisfaction. ●

Indications and contraindications Advanced thumb CMC joint disease may result in instability, subluxation of the thumb metacarpal, MCP joint hyperextension, and pain at rest or with activity. In general, thumb CMC arthroplasty is indicated in patients who have failed conservative treatments such as immobilization, rest, non-steroidal anti-inflammatory drugs (NSAIDs), and intra-articular steroid injections and have pain at rest or pain interfering with daily activities. These patients have stage II–IV disease. Regardless, conservative measures usually have only a short-lived effect and are unlikely to help in advanced disease. The use of tendon interposition or suspension for thumb CMC reconstruction should be approached with caution in patients with RA or other inflammatory conditions because of the likelihood of degenerative changes in the tendon, resulting in an unstable reconstruction. Arthrodesis is sometimes preferred to arthroplasty in young patients and heavy laborers with isolated trapeziometacarpal arthritis, because of the greater ability of the reconstruction to withstand high forces generated by pinch and grip. Arthrodesis relieves pain and improves strength and stability. However, the drawbacks compared to arthroplasty include reduced oppositional mobility of the thumb, inability to flatten the hand, requirement for a prolonged period of immobility, and a higher incidence of complications that require reoperation.3

Arthrodesis candidates must have good IP and MCP mobility. The procedure is contraindicated in patients with arthrosis of multiple joints of the thumb.

Preoperative history and considerations Patients frequently present with complaints of weakness and pain at the base of the thumb, particularly with pinch and grip. On examination, patients often demonstrate a painful grind test with axial compression and circumduction of the thumb, local tenderness, swelling, and crepitus at the CMC joint. More advanced disease can be accompanied with dorsal subluxation of the thumb metacarpal and loss of motion due to adduction contracture. All patients should have radiographic studies of both hands, including AP, lateral, and stress views. Radiographs will reveal cartilage erosion, sclerosis, osteophyte formation, joint space abnormalities, and instability on stressing the CMC joint. The decision to proceed with surgery must be based on the severity of the patient’s complaints. A severely destroyed joint is not an indication for surgery; rather, incapacitating pain that affects activities of daily living is the most appropriate indication. When planning to proceed with thumb CMC arthroplasty, it is also important to evaluate whether there is hyperextension of the thumb MCP joint. Hyperextension deformity of the thumb MCP joint accompanies CMC arthritis because of the compensatory need for the patient to abduct and extend the thumb. If more than 30º of MCP joint hyperextension is present during key pinch, arthrodesis or volar capsulodesis of the MCP joint should be considered and can be performed at the same time as CMC arthroplasty.

Operative approach Complete trapeziectomy with a modified APL suspension arthroplasty is the technique preferred by the senior author. This approach is a simpler alternative to the widely used FCR technique, and outcomes with its use are similar to those of other methods reported in the literature.4 The technique uses a slip of the APL tendon to anchor the metacarpal base of the thumb to the index finger metacarpal, which helps to maintain axial and translational stability after trapeziectomy. All procedures are performed under regional or general anesthesia with tourniquet control.

Preferred technique: modified APL suspension arthroplasty A 3-cm longitudinal incision is made dorsally over the anatomic snuffbox (Fig. 12.8). The APL/EPB (extensor pollicis brevis) and extensor pollicis longus (EPL) tendons are identified within the first and third extensor compartments, respectively, and make up the lateral borders of the snuffbox (Fig. 12.9). Dissection is carried down between the EPL and APL tendons, which are retracted ulnarly and radially, respectively. Radial sensory nerve branches must be protected with gentle retraction throughout the dissection. The deep branch of the radial artery is seen as it courses through the snuffbox and over the scaphotrapezial joint.


FIGURE 12.8 Distal skin incision over the anatomic snuffbox, and proximal skin incision over the radial styloid.

FIGURE 12.10 The trapezium is exposed through a longitudinal capsular incision.

FIGURE 12.9 APL and EPL tendons are identified and form lateral borders of the anatomic snuffbox.

Small branches of the radial artery to the joint capsule are cauterized with bipolar electrocautery to allow mobilization and retraction of the artery. Care must be taken to avoid injury to the radial artery. The capsule of the first CMC joint is now visible in the base of the wound. The trapeziometacarpal joint is opened with a longitudinal incision through the joint capsule (Fig. 12.10). An oscillating saw is used to divide the trapezium into thirds, and this is then removed in parts with a rongeur. The FCR tendon lies in the trapezial groove on the volar surface of the bone. It is protected during the trapeziectomy by not allowing the oscillating saw to advance entirely through the volar surface of the trapezium. All remaining osteophytes must be removed with the rongeur after the trapeziectomy. Next the APL tendon is harvested from its musculotendinous junction. A separate 2 cm chevron incision is made at the first extensor compartment over the radial styloid (see Fig. 12.8). Again, care must be taken to protect branches of the radial sensory nerve. The first extensor compartment is released, which contains the APL and EPB tendons. The two tendons are often contained in separate compartments within the first extensor compartment, hence only release of the APL tendon is necessary in this case. Typically the

FIGURE 12.11 Radial slip of the APL tendon is detached from the musculotendinous junction.

APL consists of three slips at its origin. The most radial slip is detached from the musculotendinous junction (Fig. 12.11). The entire APL tendon should not be divided. The divided end of the tendon is freed from soft tissue attachments and is pulled into the distal incision (Fig. 12.12). The distal aspect of the divided slip of APL tendon is freed from remaining attachments all the way to its insertion at the base of the thumb metacarpal. A length of approximately 5–6 cm of tendon should be available after harvest. The tendon slip will be used to suspend the thumb metacarpal for added stability after trapeziectomy. The freed slip of APL tendon is passed under the EPB tendon and woven into the extensor carpi radialis longus (ECRL) tendon (Fig. 12.13). The ECRL tendon can be identified as it inserts on the index metacarpal. The woven APL tendon is secured to the ECRL tendon using 3/0 non-absorbable


FIGURE 12.12 The APL tendon slip is detached from tissue attachments and pulled into the trapeziectomy site.

FIGURE 12.14 APL slip is woven into the ECRL tendon at the base of the index metacarpal.

running subcuticular suture to approximate the skin. A soft surgical dressing is applied over the incisions. The patient is placed in a well-padded spica plaster splint to immobilize the thumb in slight abduction and pronation.

Alternative techniques

EPB

Weaved juncture Dorsal slip of APL ECRL APL

FIGURE 12.13 Overview of APL suspension arthroplasty. The radial slip of the APL tendon is detached, brought under the EBP tendon and woven into the ECRL tendon.

braided suture (Fig. 12.14). Any remaining free end of the tendon is trimmed. Typically, after using the slip of APL tendon to suspend the thumb metacarpal, there is insufficient tendon remaining to place in the trapezial space for interposition. The joint capsule is closed with absorbable sutures. The tourniquet is released and hemostasis achieved using bipolar electrocautery. Both incisions are closed in a layered fashion, with absorbable sutures placed in the dermal layer and a

Several variations of the APL technique exist. The Thompson suspension arthroplasty5 uses a slip of the APL tendon and suspends the thumb metacarpal by tunneling the tendon through two burr holes created in the base of the metacarpal. Alternatively, the APL tendon can be tunneled volar to the EPB and brought around or through the FCR tendon. It is then brought back into the trapezial void and can be secured tightly to the EPB or APL tendons to maintain suspension of the thumb metacarpal. If sufficient tendon remains, it can be rolled and placed in the void as a spacer, otherwise the remaining APL tendon is trimmed at its free end. Arthroplasty without suspension has also been described. The harvested tendon (APL, FCR, or PL) is rolled or folded onto itself and simply placed in the trapezial void to function as a spacer. Suspension or interposition of the thumb metacarpal with the FCR tendon is also widely used. The disadvantage of use of the FCR tendon is that the soft tissue dissection required for harvest is more extensive, and several incisions are made for the harvest alone. Short transverse incisions (typically four) over the course of the FCR tendon are made from the wrist crease, proximal to the musculotendinous junction. The incisions are spaced 2–3 cm apart to harvest 10–12 cm of tendon. Approximately one-third of the tendon is dissected free from the musculotendinous junction and is passed distally to the site, where it is visualized in the trapeziectomy void. Care must be taken to protect the palmar sensory branch of the median nerve during tendon harvest. The tendon can then be used simply as interposition material alone, or may be used to suspend the thumb metacarpal, as described by Eaton et al.6 For suspension arthroplasty, drill holes are made in the base of the thumb

170 Hand and Upper Extremity Reconstruction metacarpal in the sagittal plane (perpendicular to the nail plate), and the FCR tendon is passed through the holes from volar to dorsal. It is then secured to the APL tendon and capsule. The remaining free end of the tendon is used as interposition material and is placed in the trapezial space.


●

●

●

Protect the branches of the radial sensory nerve and radial artery during dissection. Irritation of or injury to this nerve is not an unusual complication of this procedure. Branches of the nerve must be identified and gently retracted away. If FCR is harvested in an alternative approach, protect the palmar sensory branch of the median nerve. Completely excise osteophytes, paying particular attention to the space between the thumb and index metacarpals. Failure to remove the osteophytes in this area can result in persistent postoperative pain and the need for reoperation. Patients should be warned that improvement of symptoms after surgery is not immediate, and can often continue for several months and even years after surgery. For men who engage in manual labor recovery can take several months, and potential patients must be educated regarding the slow recovery of grip strength and the unpredictable delay of return to work.

Complications The most common complications after surgery include altered sensibility in the radial sensory nerve distribution, or neuroma formation, soft tissue infection, and persistent pain. Most of these common complications are easily treated. Radial sensory nerve dysesthesia usually improves with time and observation. If symptoms of neuroma are present, desensitization or excision is required for relief. Careful dissection and protection of the radial sensory nerve at the time of the initial operation will keep the incidence of this complication low. Soft tissue infection most often resolves with a course of intravenous antibiotics, as no foreign material is introduced in this arthroplasty method. Persistent pain at or worse than preoperative levels is rare in CMC arthroplasty. Most patients note a substantial improvement in pain. A common source of persistent pain is the presence of residual osteophytes. Care must be taken during the initial operation to ensure that all osteophytes are removed. If not, the patient may require a subsequent procedure to remove the residual osteophytes. Regional pain syndrome is a rare complication of thumb CMC arthroplasty that may result in a poor postoperative outcome. When suspected, patients should receive early and aggressive treatment with appropriate pharmacologic therapy, sympathetic blocks, and hand therapy. Lastly, some degree of shortening of the thumb ray is to be expected after trapeziectomy and cannot be completely avoided, even

when suspension arthroplasty is performed. Rarely do patients complain of symptoms indicating impingement of the metacarpal onto the scaphoid.

Postoperative care Typically, all arthroplasty procedures can be performed on an outpatient basis. The patient should return in 2 weeks for splint removal and the placement of a custom thermoplast resting splint. The patient should begin seeing a hand therapist to begin progressive active range of motion (ROM) exercises of the thumb and wrist 4 weeks after surgery. The thermoplast splint should be worn for protection and comfort between ROM exercises. The patient can gradually wean from the splint at 6–8 weeks after surgery, at which time unrestricted passive ROM exercises should be initiated. Gentle strengthening may begin 6–8 weeks after surgery. Normal use of the hand with daily activities is anticipated 10–12 weeks after surgery.

MCP ARTHROPLASTY Stiffness or deformity at the MCP joints can be quite disabling because the majority of the arc of finger flexion originates at the MCP joint. MCP joint abnormalities are most commonly due to the effects of RA, causing destruction of the joint with volar dislocation and ulnar drift. Post-traumatic and rarely idiopathic osteoarthritis may also affect individual MCP joints, causing stiffness and pain. Silicone implants are the most reliable arthroplasty technique to replace destroyed joints in the rheumatoid hand. Both silicone and pyrolytic carbon implants are used in post-traumatic and idiopathic arthritis at the MCP joint, offering an alternative to arthrodesis to preserve motion. For OA of the MCP joint, the senior author now prefers the pyrolytic carbon implant because of the much greater motion than with the silicone type. The ligament structure at the MCP joint provides excellent support for this twopiece implant. However, in RA patients the weak ligament support structures and the deforming forces make the stability of pyrolytic carbon arthroplasty less predictable. This implant is not favored by the senior author for the treatment of the rheumatoid hand. For RA, in general, the gains in the degree of active arc of motion after arthroplasty are modest at best. However, great improvement in pain and a more extended and functional arc of motion is achieved by allowing the hand to open and grasp larger objects.7–10

Indications and contraindications The decision to proceed with arthroplasty must be made carefully by selecting the patients most likely to benefit from the procedure, and excluding those unlikely to see large improvements in function. Indications include significant pain unresponsive to conservative measures, such as medical management of inflammatory conditions, splint-

Arthroplasty Procedures in the Hand 171 ing, activity modification, analgesics, and corticosteroid injections. Other indications include severe or fixed deformity at the MCP joints limiting function, which may manifest as joint destruction, subluxation, and severe ulnar deviation, typically greater than 30º. There are many RA patients who have significant deformity. However, some of these are able to maintain a reasonable level of function and may not improve to a significant degree after joint reconstruction. Thus, arthroplasty should be limited to patients who have severe functional impairment, and in general they should have an arc of motion less of less than 40º and fingers in a poor functional flexed position. Arthroplasty is not indicated in patients who are able to achieve an active arc of motion greater than 60º, as arthroplasty is typically unable to result in improvement of motion in these patients, and in fact may result in diminished motion postoperatively. Other contraindications for arthroplasty include poor skin coverage or quality, inadequate bone stock to support an implant, an irreparable musculotendinous system, and active infection. Patients with active inflammation of the MCP joint should not undergo implant arthroplasty until the inflammation has been adequately treated to avoid a potential postoperative inflammatory response in the hand and infection. Patients with MCP joint disease of the thumb due to inflammatory conditions are usually best served with arthrodesis, which can withstand the lateral stresses generated by pinch and can provide adequate pain relief.

Preoperative history and considerations The importance of the preoperative assessment of global function of the patient, the upper extremity, and the hand cannot be stressed enough. Concentrating solely on the MCP joints and ignoring higher-priority deformities will result in poor postoperative results. Lower extremity and more proximal upper extremity joints should be treated before finger joints. Thus evaluation of the wrist, elbow, and shoulder is critical in the preoperative examination. Wrist deformities must be treated first because persistent uncorrected wrist deformity will result in early recurrence of ulnar deviation at the MCP joints. The status of the flexor and extensor tendons should be documented. The surgeon should contemplate simultaneous joint and tendon reconstruction, or perhaps a staged procedure with joint reconstruction first to achieve good passive joint motion prior to tendon reconstruction. Adjacent joint deformities at the PIP and DIP joints should also be noted. Swan-neck deformities commonly accompany the volar subluxation and ulnar drift present in the rheumatoid hand, and may be corrected by soft tissue reconstruction at the same time as MCP arthroplasty. Three-view radiographs of the hand and wrist are taken preoperatively to evaluate the extent of bone erosion, or other areas of destruction in the hand and wrist that may require treatment. It is critical to remember that RA is a progressive medical disease. Medical therapy must be optimized and all patients should be followed closely by a rheumatologist.

When performing MCP arthroplasty in a patient with accompanying deformities, such as extensor tendon rupture or swan-neck/boutonnière deformity, the surgeon should consider whether it is better to perform a staged or a simultaneous reconstruction. If extensor tendons are ruptured, the traditional approach is to regain joint mobility first, then perform tendon reconstruction. In a compliant patient who has good therapist support, joint and tendon reconstruction may be performed simultaneously. If the patient has a swan-neck deformity, the surgeon may wish to perform MCP arthroplasty first, before treating the swanneck deformity. Patients with swan-neck deformity of the fingers will need to maximize flexion at the MCP joint because of the hyperextension deformity at the PIP joint. Therefore, theoretically, they will stress the reconstructed MCP joints to achieve better flexion and increased joint motion. On the other hand, patients with boutonnière deformity already have flexed digits and may not stress the MCP joints sufficiently after MCP arthroplasty. Whether to perform staged or simultaneous reconstruction depends on understanding the needs of the patient and the ability of the surgeon to maximize the biomechanical advantage of the reconstructive procedures, based on the existing deformity.

Operative approach

Silicone metacarpophalangeal arthroplasty (SMPA) Arthroplasty of all four MCP joints of the index through to the small fingers is often needed. A dorsally placed transverse incision is made over the heads of the metacarpals (Fig. 12.15). Dissection is carried down to the extensor apparatus, carefully preserving the longitudinal dorsal veins to limit postoperative swelling. The skin is carefully retracted with traction sutures. In the rheumatoid hand the extensor apparatus is probably deviated ulnarly from the head of the metacarpal (Fig. 12.16). The radial sagittal bands are incised to expose the MCP joints (Fig. 12.17). A longitudinal incision is made in the joint capsule to expose the joint surface. Any synovial tissue present is sharply excised. An oscillating saw is used to resect the metacarpal heads just distal to the origin of the collateral ligament (Fig. 12.18). The metacarpal heads are removed. Remaining

FIGURE 12.15 SMPA dorsal skin incision over the metacarpal heads.


FIGURE 12.16 View of extensor apparatus, which is seen ulnarly deviated from the center of the metacarpal head.

FIGURE 12.17 Exposure of MCP joint after incision of radial sagittal band. (Removed synovitis on dorsal hand.)

FIGURE 12.18 Resection of metacarpal heads.

FIGURE 12.19 Insertion of awl to prepare medullary cavities for placement of implants.

FIGURE 12.20 Insertion of non-absorbable suture into metacarpal shaft for repair of radial collateral ligaments.

synovial tissue should be excised. Mobility of the fingers in the radial and ulnar directions should be assessed. If there are forces pulling the fingers in the ulnar direction, it is likely to be caused by chronic contracture of the ulnar intrinsic tendons. The ulnar intrinsic tendons and abductor digiti minimi are sharply released to remove these deforming forces. However, if enough of the metacarpal head is removed, the ulnar deforming forces should be relieved and resection of the ulnar intrinsic tendons is unnecessary. Next, the MCP joint is prepared for fit and sizing of the implant. An awl designed for use with the silicone implant is used to perforate the medullary cavities of the metacarpals and proximal phalanges (Fig. 12.19). Sequentially sized broaches are used to enlarge the medullary cavity to receive the implant. The largest implant that will fit in the medullary cavity without impairing the range of motion is used.

Arthroplasty Procedures in the Hand 173 surgical site, and the patient is placed in a well-padded plaster splint with the MCP joints in extension and slight radial deviation.

Pyrocarbon metacarpophalangeal arthroplasty

Radial collateral ligament

A

Silicone arthroplasty implant

B

FIGURE 12.21 Radial collateral ligament repair. A Two burr holes are made in the radial metacarpal shaft, through which non-absorbable sutures are placed. B The suture is then used to reattach the radial collateral ligament after the silicone implant is placed in the medullary canals.

Before placing the permanent implant, two drill holes are made with a 0.035 inch K-wire through the distal radial metacarpal shaft. These holes are for repair of the radial collateral ligament; 3/0 non-absorbable braided sutures are placed through the two drill holes, keeping the needle attached and set aside (Fig. 12.20). The permanent implants are inserted into the medullary canals. The suture attached to the metacarpal shaft is used to repair the radial collateral ligament (Fig. 12.21). When tying the suture to secure these ligaments, the fingers are brought into slight radial deviation. If there is tension in doing so, the ulnar intrinsic tendons (lateral bands) must be released if not already done. The released ends of the ulnar lateral bands can be transferred to the radial lateral band of the adjacent finger for added stability against ulnar deforming forces. For example, the ulnar lateral band of the middle finger is released and secured to the radial lateral band of the ring finger (Fig. 12.22). The radial sagittal band is then repaired with 3/0 absorbable braided suture, being sure to imbricate the closure so that the extensor apparatus is situated centrally over the MCP joint (Fig. 12.23). If the extensor tendons cannot be easily centralized over the metacarpal head owing to tightness of the ulnar sagittal bands, the ulnar sagittal bands must also be released. The tourniquet is released and bipolar electrocautery is used to control bleeding. The skin is closed with interrupted absorbable sutures in the dermis and interrupted horizontal mattress nylon sutures to approximate the skin. A soft dressing is applied over the

A dorsal curvilinear incision is made longitudinally over the MCP joint for single joint replacement. For multiple joint replacements, a single transverse incision is made over the dorsal metacarpal heads (Fig. 12.24). Dissection is carried down to the extensor apparatus, carefully preserving the longitudinal dorsal veins to limit postoperative swelling. The radial sagittal band is incised and the extensor tendon retracted to expose the MCP joint. A longitudinal incision is made in the joint capsule to expose the joint surfaces. A starter awl is placed in the metacarpal head one-third of the distance from the dorsal cortex, advancing one-half to twothirds of the metacarpal length (Fig. 12.25). The alignment guide on the starter awl is used to make a 27.5º distally tilted proximal osteotomy 1.5 mm distal to the collateral ligament attachment site (Fig. 12.26). After starting the osteotomy, the awl will have to be removed to completely cut through the volar cortical surface. Every effort should be made to preserve the attachments of the collateral ligaments on the metacarpal head and base of the proximal phalanx. The starter awl is used to create a medullary canal at the base of the proximal phalanx, advancing one-half to two-thirds of its length. Using the awl and alignment guide, one will make a 5º distally tilted osteotomy (Fig. 12.27). A series of broaches made specifically for the pyrocarbon implant are inserted into the metacarpal and proximal phalanx to prepare medullary canals for the implant stems (Fig. 12.28). The size of broaches used is increased to the largest that can be fully accommodated within the canal. Broaches are inserted under fluoroscopic guidance to ensure the instrument is fully inserted and directed in the center of the medullary canal. No mismatching of paired implant sizes is allowed in MCP pyrocarbon arthroplasty, hence the same size broach must be used for the metacarpal and proximal phalanx canals. A trial implant is secured in place using the proximal and distal impactor, making sure the implant is press-fitted tightly in contact with the cortical surface of the bone (Fig. 12.29). Joint mobility is evaluated. If there is difficulty with passive extension, more resection of the metacarpal is required for a better fit of the prosthesis. If detachment of the collateral ligaments is required during bone resection, both radial and ulnar collateral ligaments are repaired in a similar fashion as described for the SMPA technique. If the trial implant allows adequate range of motion, the permanent implant is press-fitted into the medullary cavities (Fig. 12.30) by tapping it gently with the supplied impactor (Fig. 12.31). The joint capsule and radial sagittal band are repaired with absorbable sutures. The tourniquet is released and bipolar electrocautery is used to control bleeding. The skin is closed with interrupted absorbable sutures in the dermis and interrupted horizontal mattress nylon sutures to approximate the skin. A soft dressing is applied over the surgical site. A well-padded plaster splint is applied with the MCP joints in extension.


Central slip of extension apparatus

FIGURE 12.22 Tightness of ulnar intrinsics necessitates release of ulnar lateral bands and ADM. The released lateral band may be transferred to the adjacent radial lateral band for added stability.

Lateral bands

Released ulnar lateral band

MCP joints with SMPA in place ADM (not transferred)

IF

MF

RF

SF

Incision for multiple joint replacement

Incision for single joint replacement

FIGURE 12.23 Imbrication of the radial sagittal band to relocate the extensor apparatus over the center of the metacarpal head.

FIGURE 12.24 Skin incisions for single or multiple MCP pyrocarbon arthroplasty.

Arthroplasty Procedures in the Hand 175 Dorsal third of metacarpal head Metacarpal

Starter awl

Proximal phalanx

Distal osteotomy guide

FIGURE 12.25 The starter awl is placed into the metacarpal head one-third the distance from the dorsal cortex.

5°

Alignment awl

Electrical saw

Proximal osteotomy guide

27.5°

FIGURE 12.27 The awl and alignment guide are inserted. A 5º distal osteotomy is created at the base of the proximal phalanx.

Alignment awl

●

●

FIGURE 12.26 The alignment guide is placed on the starter awl and the oscillating saw is used to make a 27.5º osteotomy just distal to the collateral ligament origin at the metacarpal head.

●


●

●

Ensure that proximal joint deformities are addressed before the finger joints, because unaddressed radial deviation of the wrist will inevitably result in ulnar deviation at the MCP joints. Focusing solely on the MCP joint will lead to unsuccessful outcomes if other joints are contributing to MCP joint deformity and instability. Know the status of flexor and extensor tendons, and whether repair is needed prior to arthroplasty. Otherwise, the patient will gain little motion after arthroplasty if tendons are unable to function properly. During silicone arthroplasty the proximal phalanx of the index finger is reamed in a slightly supinated position for better tip pinch position.

●

A no-touch technique with smooth forceps should be used when handling the silicone implant to avoid damaging its surface. Such damage can lead to propagation of defects in the implant and later fracture. Stability of the joint and prevention of early ulnar drift is maintained by tightening the radial sagittal bands to centralize the extensor tendons and by dividing or transferring the ulnar intrinsic tendons in patients with rheumatoid arthritis. Realistic expectations of the surgeon and patient must be emphasized. The active arc of motion may not increase dramatically after any arthroplasty technique, and results are likely to diminish over time, especially in patients with rheumatoid arthritis. The active arc of motion achieved after surgery is usually not more than 60º, but the arc is in a more extended position that will allow the hand to open to hold larger objects. Patients have to decide whether large improvements in the short term justify undergoing the procedure. The appropriate implant type must be used, based on the underlying disease, the competence of supporting tissues and bone, and anticipated functional demands.

Complications The most common complications of MCP arthroplasty with both silicone and pyrocarbon implants include soft tissue infection, implant failure or dislocation, and


A

B

FIGURE 12.28 The medullary canals of the proximal phalanx (A) and metacarpal (B) are prepared to receive the implant by inserting broaches of increasing size.

Trial implant

FIGURE 12.29 The trial implant is gently press-fitted with the impactor.

recurrent deformity. Soft tissue infection is rare, requiring treatment with intravenous antibiotics and removal of the implant if the infection does not immediately resolve. Silicone implant fracture in most cases does not require exchange of the implant because it is most often asymptomatic. The capsule formed around the implant during healing maintains long-term joint stability. Recurrent ulnar drift, extensor lag, and loss of motion are expected in the long term after arthroplasty in patients with rheumatoid arthritis. Patients should be educated that results in the immediate postoperative period are not permanent, and can change with time as their disease progresses and implants are worn. However, improvement from the preoperative level of function and pain is sustained long term. Patients receiving silicone and pyrocarbon arthroplasty may have changes in the bone surrounding the implant, with osseous erosions that may lead to metacarpal or proximal phalanx shortening or subsidence. Bone erosion is usually more pronounced with silicone arthroplasty than with pyrocarbon arthroplasty, probably due to silicone synovitis. Patients who experience dislocation of the pyrocarbon implant usually do so in the early postoperative period. Early dislocation is typically managed with closed reduction and prolonged immobilization of the joint by external fixation or prolonged splinting before hand therapy is begun. Excluding patients with poor ligamentous support of the joints will reduce the risk of dislocation of the pyrocarbon implant.


Implant

FIGURE 12.31 The permanent implant is press-fitted against the cortical surfaces of the bone.

Postoperative care The splint placed at the time of surgery is removed at the first postoperative visit 4–7 days later. An extension resting splint is fabricated for night use. A dynamic extension splint is used during the day to control motion during active exercises. The dynamic splint is worn during the day for 6–8 weeks, and the resting splint is worn at night for 12 weeks. Sutures are removed 2 weeks postoperatively. The goal of MCP flexion is 60º at 4 weeks. Patients are able to progress to light activities with the hand at 6 weeks, and gentle strengthening at 8 weeks after silicone arthroplasty. Return to normal activities by 12 weeks with night splinting as needed should be expected. Patients receiving pyrocarbon arthroplasty are able to progress to full activities as tolerated 6 weeks after surgery. Night splinting is continued as needed. Frequent examination by a hand therapist is required to adjust splints as necessary.

PIP ARTHROPLASTY

FIGURE 12.30 X-ray showing the pyrocarbon MCP implant.

Arthroplasty should be considered if the patient desires motion, and if soft tissue reconstructive procedures such as capsular release or tendon relocation procedures are no longer possible because the joint is severely arthritic. For a patient presenting with a boutonnière deformity, PIP arthroplasty, in most cases, should not be performed. These patients are still able to make a full grip, provided that MCP joint motion is reasonable. PIP arthroplasty will place the PIP joint in extension, which will limit grip and can be a hindrance to the patient. Additionally, the amount of bone resection necessary to correct flexion deformity of the PIP joint will require excision of the collateral ligaments, which will destabilize the joint. This is particularly problematic for two-piece pyrocarbon implants, in which the integrity of the collateral ligament is crucial to the stability of the reconstructed joint. In most cases, boutonnière deformity is an aesthetic consideration and not a functional one. On

178 Hand and Upper Extremity Reconstruction the other hand, patients with swan-neck deformity have difficulty with PIP joint flexion. Their grip is weak because of limited PIP motion. PIP arthroplasty can enhance PIP joint flexion and is a much preferred option. PIP joint arthroplasty should be considered carefully for the index finger because the supporting ligaments may not be durable enough to withstand lateral forces, and thus arthrodesis is recommended to maintain lateral stability for pinch. Arthroplasty is preferred in the ulnar digits because they are important in grip, and preservation of motion is needed. The middle finger functions in both grip and pinch, therefore either arthrodesis or arthroplasty is reasonable. The PIP pyrolytic carbon implant was approved for use in the US as a humanitarian device in 2002. Although no long-term data are available to show an advantage over silicone arthroplasty, range of motion after pyrocarbon arthroplasty is similar to the results of silicone arthroplasty.11 This procedure is a promising alternative in patients who are poor candidates for silicone arthroplasty. Because of the anatomic design of the pyrolytic carbon PIP implant, it has become preferred for OA joints. Again, the senior author is reluctant to use this implant type for RA patients because of weak ligament support in RA joints.

Indications and contraindications/preoperative history and considerations

Reflected extensor tendon

Central extensor tendon

Proximal interphalangeal joint

Lateral band

FIGURE 12.32 Exposure of PIP joint by distal reflection of central slip.

The considerations for PIP arthroplasty have been discussed and are similar to the issues presented for MCP arthroplasty.

Operative approach

Pyrolytic carbon PIP arthroplasty Pyrolytic carbon PIP arthroplasty is very similar to MCP pyrocarbon arthroplasty, with subtle variations. Under tourniquet control, a 2–3 cm longitudinal curvilinear incision is made over the dorsum of the PIP joint. There are two methods that may be used to retract the extensor mechanism for joint exposure. The widest exposure is obtained by making a chevron incision in the extensor tendon at the level of the mid-proximal phalanx. This allows the central slip to be detached and retracted distally to expose the joint (Fig. 12.32). This method will require tendon repair after implant placement. There is a risk of stretching the detached and repaired extensor tendon during therapy, and the resulting extensor lag may require prolonged extension splinting. Alternatively, the senior author’s preference is to expose the joint with a tendon-splitting incision through the central slip of the extensor mechanism. The tendon is incised longitudinally, taking care not to disrupt the distal insertion, and the tendon edges are retracted to expose the joint (Fig. 12.33). At the time of closure, the tendon is repaired in a side-to-side fashion. Ideally, adequate joint exposure can be obtained without detaching the attachment of the central slip. However, if detachment is necessary, the tendon is repaired by placing sutures through holes drilled over the dorsal base of the middle phalanx.

Lateral band

Exposed PIP joint Reflected split central slip

Central extensor tendon

FIGURE 12.33 Exposure of PIP joint by making a longitudinal slit through central slip and retraction. This approach allows preservation of the continuity of the extensor apparatus.


Alignment guide

Alignment awl

Electrical saw Proximal phalanx Vertical cutting guide

Alignment awl

A

B

FIGURE 12.34 The starter awl is placed between the condyles at the head of the proximal phalanx (A) and the alignment guide is used to make a vertical osteotomy (B).

The surface of the proximal phalanx is prepared first. A starter awl with alignment guide is placed between the condyles of the head of the proximal phalanx to create a medullary canal for the prosthesis. The vertical cutting guide with an oscillating saw is used to make a vertical osteotomy though the head of the proximal phalanx, 1– 2 mm distal to the attachment of the collateral ligaments (Fig. 12.34). A series of broaches of increasing size are used to prepare the medullary canal to fit the largest broach that can be accommodated. Broaches are inserted under fluoroscopic guidance to ensure the instrument is fully inserted and directed in the center of the medullary canal. The 60º oblique cutting guide is placed in the prepared medullary canal of the proximal phalanx to make a second osteotomy, oriented in the volar oblique direction (Fig. 12.35). All osteophytes are gently removed with a rongeur. The proximal phalanx is now ready to press-fit the trial implant. Next, the middle phalanx is prepared. A small oval burr is used to remove just the articular surface at the base of the middle phalanx and create a gentle trough to accommodate the implant. No osteotomy is made. In a similar fashion as for the proximal phalanx, a series of broaches are used to prepare the medullary canal to fit the largest implant that can be accommodated. Unlike the MCP pyrocarbon implants, paired PIP pyrocarbon implants can be mixed one size up or down, such that the proximal phalanx and middle phalanx components may differ by one size increment. The trial implant is press-fitted into the middle phalanx. The shoulders of both implants must rest against the cut edge of the cortical bone for appropriate fit. Motion at the PIP joints is assessed with the trial implant in place to assure smooth, unrestricted movement. If the implant is so tight as to impede motion, additional bone should be

Alignment guide Proximal phalanx 60° Electrical saw

Middle phalanx

A Collateral ligament

B FIGURE 12.35 After the medullary canal of the proximal phalanx is broached, the 60º oblique cutting guide is inserted in the canal and a second osteotomy is made (A). Both the vertical and 60º oblique osteotomies are made so as to not disturb the attachment of the collateral ligament (B).

resected from the proximal phalanx. Tenolysis may be required if there are any limitations in passive motion. The permanent implant is press-fitted by gentle tapping. The extensor tendon is closed in a side-to-side fashion with interrupted non-absorbable sutures. The incision is closed with horizontal mattress nylon sutures to approximate the skin. A soft sterile dressing is applied over the incision, and

180 Hand and Upper Extremity Reconstruction a well-padded plaster splint is applied with the finger in full extension.

Alternative technique The silicone arthroplasty remains the most widely used technique for reconstruction of PIP joint deformities, specifically of the ulnar digits. Joint exposure is identical to that described for the PIP pyrocarbon implant, using the tendon-splitting technique to avoid disrupting the continuity of the extensor tendon. The head of the proximal phalanx is resected vertically with an oscillating saw without disrupting the attachments of the collateral ligaments. The medullary canals of the proximal and middle phalanges are prepared by inserting broaches of increasing size, identical to the method used for placement of silicone implants at the MCP joint. The implant is gently inserted with smooth forceps and joint mobility is assessed to ensure adequate implant sizing. The extensor tendon and incision are closed as described in the PIP pyrocarbon arthroplasty procedure. The finger is splinted in full extension. The volar approach can be used as well. The advantage of this technique is that the extensor tendon over the PIP joint is not violated. The PIP joint is exposed after careful preservation of the neurovascular bundles. The PIP joint is exposed via a shotgun approach, and the rest of the procedure is similar to the dorsal approach. The senior author prefers the dorsal approach because of the ease of exposure.


●

●

●

Minimal joint resection helps to preserve the attachments of the collateral ligaments, and leaves a wider cortical contact surface area for distribution of compressive loads onto the implants. The collateral ligament attachments should be preserved whenever possible to maintain stability. The extensor apparatus should be shortened to correct laxity in cases of chronic flexion deformity. Tenolysis may be necessary at the time of arthroplasty, and can improve motion after surgery.

Complications Complications common to both pyrolytic carbon and silicone arthroplasty at the PIP joint are similar to those seen at the MCP joint. Patients may develop changes in the bone surrounding the implant, leading to erosions, loosening, subsidence, or instability, which may require implant removal and arthrodesis. Heterotopic bone formation can be seen with silicone arthroplasty. Reoperation for implant fracture seen with silicone implants is rarely needed owing to the formation of a stabilizing capsule around the implant. If the joint is unstable, the implant is replaced if bone quality is adequate, or arthrodesis is performed. Infection is rarely encountered after PIP arthroplasty, but if the infection does not resolve patients are treated with intravenous antibiotics and implant removal. Pyrolytic implants have

FIGURE 12.36 Photograph showing external fixator in place to correct a dislocated implant.

occasionally been reported to squeak, but this usually improves with time. Implant dislocation is a difficult complication to treat with the PIP pyrocarbon implant. This is usually caused by poor patient selection (in boutonnière deformity) or injudicious detachment of the collateral ligaments. This complication can be treated by joint reduction and prolonged external fixation stabilization of the reduced joint (Fig. 12.36). After 6–8 weeks of immobilization, the scarring around the implant may stabilize the joint.

Postoperative care The patient returns for the first postoperative visit in 4–7 days, at which time the plaster splint is removed. A forearmbased resting splint is made to keep the MCPs in slight flexion and the IP joints in full extension for night use. A dynamic PIP extension splint is made for use during the day. Active range of motion using the dynamic splint is begun, allowing 0–30º of flexion; 1–2 weeks after the surgery up to 45º of flexion is allowed if no extensor lag is present. At 6 weeks after surgery the arc of motion is increased to 60º and light activities out of the splint are initiated, avoiding lateral stresses at the joint. Gentle strengthening may be initiated by 8 weeks after surgery. Patients are weaned from the dynamic splint in 6–8 weeks and from the night splint after 3 months. The patient should be closely followed by a hand therapist to monitor for hyperextension or extensor lag. This requires adjustment of splints and changes in the arc of motion.

CONCLUSION Arthroplasty procedures in the hand are most commonly performed at the thumb CMC and at the finger MCP and PIP joints. Most arthroplasty procedures result in a reliable improvement of pain, maintain some degree of mobility, restore alignment, and are associated with a high rate of patient satisfaction. Despite the likelihood that results will

Arthroplasty Procedures in the Hand 181 diminish somewhat over the long term, arthroplasty offers definite advantages over arthrodesis.

REFERENCES 1. Haubold AD. On the durability of pyrolytic carbon in vivo. Med Prog Tech 1994; 20: 201–208. 2. Eaton RG, Lane LB, Littler JW, Keyser JJ. Ligament reconstruction for the painful thumb carpometacarpal joint: A long-term assessment. J Hand Surg 1984; 9: 692–699. 3. Mureau MA, Rademaker RP, Verhaar JA, Hovius SE. Tendon interposition arthroplasty versus arthrodesis for the treatment of trapeziometacarpal arthritis: A retrospective comparative follow-up study. J Hand Surg 2001; 26: 869–876. 4. Chang EY, Chung KC. Outcomes of trapeziectomy with a modified abductor pollicis longus suspension arthroplasty for the treatment of thumb carpometacarpal osteoarthritis. Plast Reconstruct Surg 2007; (in press). 5. Thompson JS. Surgical treatment of trapeziometacarpal arthrosis. Adv Orthop Surg 1986; 10: 105–120.

6. Eaton RG, Glickel SZ, Littler JW. Tendon interposition arthroplasty for degenerative arthritis of the trapeziometacarpal joint of the thumb. J Hand Surg 1985; 10: 645–654. 7. Chung KC, Kotsis SV, Kim HM. A prospective outcomes study of Swanson metacarpophalangeal joint arthroplasty for the rheumatoid hand. J Hand Surg 2004; 29: 646–653. 8. Chung KC, Kowalski CP, Myra Kim H, Kazmers IS. Patient outcomes following Swanson silastic metacarpophalangeal joint arthroplasty in the rheumatoid hand: A systematic overview. J Rheumatol 2000; 27: 1395–1402. 9. Cook SD, Beckenbaugh RD, Redondo J, et al. Long-term follow-up of pyrolytic carbon metacarpophalangeal implants. J Bone Joint Surg 1999; 81A: 635–648. 10. Goldfarb CA, Stern PJ. Metacarpophalangeal joint arthroplasty in rheumatoid arthritis. A long-term assessment. J Bone Joint Surg 2003; 85A: 1869–1878. 11. Squitieri L, Chung KC. A systematic review of outcomes and complications of vascularized toe joint transfer, silicone arthroplasty, and pyrocarbon arthroplasty for post-traumatic joint reconstruction of the finger. Plast Reconstruct Surg 2008; 121: 1697–1707.

CHAPTER

Surgical Procedures for the Distal Radius and Distal Radioulnar Joint

13

Kenji Kawamura and Kevin C. Chung

INTRODUCTION The distal radius is the most commonly fractured region in the upper extremity.1 The radius has two functionally important articulations in the wrist. The first is the radiocarpal joint, which has an ellipsoid articulation between the biconcave surface of the distal radius and the convex facets of the proximal carpal bones. The second is the distal radioulnar joint (DRUJ), which has a trochoid articulation between the sigmoid notch of the distal radius and the ulnar head, allowing pronation and supination of the forearm. Inadequate management of distal radius fractures can easily result in permanent disability of the wrist because of injuries to these two critical joints. The purpose of treatment for distal radius fractures is to restore articular congruity and normal anatomic alignment of the distal radius, and to prevent articular malalignment and the development of arthritis of the wrist. Although non- or minimally displaced stable fractures of the distal radius can be treated by cast immobilization, displaced unstable fractures require surgical treatment. The various techniques available for treating unstable distal radius fractures include percutaneous pinning,2 external fixation,3 and open reduction and internal fixation with customized implants.4–6 The recent trend for internal fixation of distal radius fractures is to use the volar locking plating system (VLPS) with fixed-angle implants, which can provide rigid fixation for fragmented and even osteoporotic bones that are not normally amenable to screw fixation.5–8 Malunion is the most common complication that occurs after distal radius fractures.9 Important radiographic measurements that may affect functional outcomes in the wrist are radial inclination (normal average: 23º), radial length (normal average: 12 mm), palmar tilt (normal average: 11º) and congruity of articular surfaces (Fig. 13.1). Loss of radial inclination causes radial deviation of the wrist, whereas radial shortening leads to incongruity of the DRUJ and positive ulnar variance. Excessive dorsal tilt results in carpal

malalignment, leading to carpal instability and arthritis. Although corrective osteotomy of the distal radius may be required for severe malunions,10 salvage procedures such as the Darrach (resection of the ulnar head)11 or Sauvé– Kapandji procedures (fusion of the DRUJ)12 are required to improve overall wrist function if symptomatic DRUJ arthritis exists. This chapter describes the following two important surgical procedures for the distal radius and DRUJ: volar plating of distal radius fractures, and the Darrach procedure.

VOLAR PLATING OF DISTAL RADIUS FRACTURES Indications and contraindications After closed reduction of distal radius fractures, unacceptable reduction parameters requiring surgery include a radial inclination of 2 mm, dorsal tilt of >10º and articular step-off of >2 mm. Volar fixed-angle plate fixation is indicated for both extra-articular and intraarticular fractures of the distal radius. Furthermore, volar fixed-angle plate fixation can even be applied to dorsally displaced fractures that have been traditionally treated with dorsal plate fixation.13 The use of volar plating can avoid the complication of dorsal soft tissue irritation associated with dorsal plate fixation. The volar anatomy of the distal radius has obvious advantages over the dorsal aspect for implant application. Specifically, there is more space between the volar cortex and flexor tendons, and the pronator quadratus separates these structures, thereby preventing soft tissue complications such as tendon rupture.14 The additional space permits the placement of larger implants. Volar fixed-angle plate fixation may be contraindicated for the less common massively comminuted fractures of the articular surface because of the technical difficulty of achieving proper reduction of the fragmented articular surface.

183


A

B

FIGURE 13.1 Radiographic parameters of the distal radius. A Radial inclination (RI) is measured relative to the perpendicular shaft of the radius, and the normal average is 23º. Radial length (RL) is the difference in length between the ulnar head and the tip of the radial styloid, and the normal average is 12 mm. B Palmar tilt (PT) is measured relative to the perpendicular shaft of the radius on the lateral view, and the normal average is 11º.

In such cases external fixation may be recommended.3 Internal fixation is not amenable to open fractures of the distal radius in emergency operations owing to concern for implant infection; external fixation is applied after debridement and irrigation of the fracture.

Preoperative history and considerations Diagnosis is usually made by standard radiographs, including posteroanterior, lateral, and oblique views (Fig. 13.2). CT is used only in rare cases to evaluate the amount of displacement of the articular surfaces. Determination of the type of fracture is important, which includes assessment of the displacement, radial shortening, intra-articular involvement, the amount of comminution, and the presence of an ulnar styloid fracture. Although numerous classification systems have been suggested for the categorization of distal radius fracture patterns,15 such as the AO, Frykman, Mayo and Melone systems, none of these is universal and capable of predicting outcomes.16 Surgeons should make an effort to restore the anatomy of the distal radius, including radial inclination (normal average: 23º), radial length (normal average: 12 mm), palmar tilt (normal average: 11º) and congruity of articular surfaces, all of which may affect the

functional outcome of the wrist. Surgeons should fix an associated ulnar styloid fracture if DRUJ instability remains after fixation of the distal radius fracture.

Operative approach The operation is performed under regional or general anesthesia with an upper arm tourniquet, and carried out with fluoroscopic assistance. The surgical approach uses an 8– 10-cm longitudinal incision located directly over the distal course of the flexor carpi radialis (FCR) tendon (Fig. 13.3).17 The incision is extended to a V-shape at the wrist crease to provide wider exposure of the fracture and to prevent scar contracture from a linear incision over the crease. Note that the distal incision should not cross into the palm. The FCR tendon sheath is opened and dissection carried down between the FCR tendon and the radial artery. The forearm deep fascia is incised to expose the flexor pollicis longus (FPL) muscle belly. The surgeon’s index finger is placed in the wound to gently sweep the FPL ulnarly, and the FPL muscle belly is partially detached from the radius to obtain full exposure of the pronator quadratus (Fig. 13.4). The distal and radial borders of the pronator quadratus are elevated with an L-shaped incision, leaving a small cuff of

Surgical Procedures for the Distal Radius and Distal Radioulnar Joint 185

A

FIGURE 13.2 A Posteroanterior B and lateral radiographs of a distal radius fracture. The radiographs show a severely comminuted intraarticular fracture with a fracture of the ulnar styloid. The distal fracture fragments are displaced and angulated dorsally.

B

FIGURE 13.3 A skin incision is made directly over the distal course of the flexor carpi radialis tendon. FIGURE 13.4 Dissection is carried down between the flexor carpi radialis tendon and the radial artery. After incision of the forearm deep fascia, the flexor pollicis longus is gently swept ulnarly by the surgeon’s index finger to expose the pronator quadratus.

186 Hand and Upper Extremity Reconstruction FIGURE 13.5 A An L-shaped incision is made on the distal and radial borders of the pronator quadratus. B Schematic drawing of an L-shaped incision on the pronator quadratus based on Figure 13.5A. FCR, flexor carpi radialis; FPL, flexor pollicis longus; PQ, pronator quadratus.

A

L-shaped incision

B

Pronator quadratus

Flexor carpi radialis Flexor pollicis longus

tissue for subsequent repair, and the muscle is retracted ulnarly (Fig. 13.5). Reduction of a dorsally displaced fracture is achieved by using a small periosteal elevator as a lever (Fig. 13.6). The dorsal fragment is reduced by applying finger pressure to the dorsal cortex. For a displaced radial styloid fracture, releasing the insertion of the brachioradialis from the radial styloid can facilitate reduction. After confirming proper reduction by fluoroscopy, a provisional K-wire can be used to fix the distal fragment to the proximal fragment temporarily. In most cases, temporary fixation is unnecessary because distal finger traction by an assistant can maintain reduction while the volar plate is placed. After placement of the volar plate, a cortical screw is first applied to the oval plate hole to fix the plate to the proximal fragment while allowing proximal or distal adjustment (Fig. 13.7). Fluoroscopic imaging is used to confirm adequate plate positioning to allow the placement of distal subchondral support pegs 2–3 mm below the subchondral bone. After accurate pre-drilling with a special threaded drill

FIGURE 13.6 A small periosteal elevator is inserted into the fracture line to serve as a lever to reduce the dorsally displaced fractures.


FIGURE 13.7 A cortical screw is first applied to the oval plate hole to fix the plate to the proximal fragment but allow proximal or distal adjustment to provide the optimal placement for the distal pegs.

A

guide, a peg is inserted into the distal fragment. One peg and one screw provide sufficient fixation to stabilize most fractures temporarily and allow fluoroscopic inspection. Fluoroscopic imaging is used to confirm that there is no intra-articular penetration of the peg. The remaining pegs are then inserted. The number of pegs to be inserted depends on the fracture configuration. At least two pegs are placed in each major fracture fragment to obtain stable fixation. The radial styloid fragment is fixed by the radialmost peg, which is angled for this purpose. The dorsal die-punch fragment is fixed by the ulnarmost pegs. After insertion of the distal pegs, the rest of the proximal cortical screws are inserted to achieve balanced fixation. Fluoroscopic imaging is used to confirm that there are no excessively long pegs or screws. The pronator quadratus is repaired with 3/0 absorbable sutures and the wound is closed. Postoperative radiographs should show a well-reduced fracture with suitable screw lengths (Fig. 13.8).

B

FIGURE 13.8 A Posteroanterior and B lateral radiographs after volar plating. The postoperative radiographs show a well-reduced fracture with suitable screw lengths.


Postoperative care and expected outcomes The wrist is immobilized with a plaster wrist splint for 1 week after the operation. After 1 week, the sutures are removed and active wrist motion is initiated. The wrist is then placed in a removable Orthoplast splint for 6 weeks. Patients who are able to engage in their own therapy can be given a home program. After 6 weeks, the patients will undergo a strengthening program. The prospective outcomes by the senior author (KCC) have shown that, despite the use of an early rehabilitation protocol, reduction of distal radius fractures can be maintained over long followup periods.6,18

Complications Complications associated with volar plate fixation for distal radius fractures are few, and frequently related to surgical technique.19 Extensor tendon injuries can occur if the pegs are excessively long, such that they protrude through the dorsal cortex and penetrate into the extensor tendon sheaths. Such injuries can be avoided with careful fluoroscopic inspection at each step of the operative procedure. Flexor tendon injuries after volar plate fixation are rare.20 Delayed healing is uncommon, but can occur if there is a loss of rigid fixation caused by inadequate reduction or plate malpositioning. Loss of fixation can occur if the pegs are placed too proximally to support the subchondral bone. Implant breakage is rare. Stiffness and reflex sympathetic dystrophy are uncommon with volar plate fixation, but must be carefully watched for and treated aggressively in their early stages if they occur.

THE DARRACH PROCEDURE Indications and contraindications Indications for the Darrach procedure (distal ulna resection) include any conditions that cause DRUJ arthritis or incongruity. The Darrach procedure is most commonly indicated in low-demand or elderly patients with persistent ulnarsided wrist pain and limited forearm rotation caused by DRUJ arthritis or incongruity following a distal radius fracture (Fig. 13.9).21,22 The procedure is also widely used in rheumatoid arthritis involving DRUJ problems such as pain, weakness, and loss of forearm rotation.23 Another important indication for the Darrach procedure is attritional rupture of the ulnar-side extensor tendons caused by a dorsally dislocated and eroded ulnar head. The Darrach procedure may be contraindicated in younger, high-demand patients.24 The distal ulna and attached soft tissues are kinematically essential for the coordination of two important movements, namely forearm rotation and wrist circumduction.25 The distal ulna is also important for maintaining adequate tension within the radioulnar interosseous membrane, allowing normal radioulnar transfer of load. Forearm motion, grip strength, and the lifting capability of the hand may frequently be impaired if the Darrach procedure is performed in younger and highdemand patients. Corrective osteotomy of the distal radius

FIGURE 13.9 Posteroanterior radiographs of severe distal radius malunion. There is radial shortening with disruption of the distal radioulnar joint.

may therefore be preferred for such patients with a distal radius malunion.10 Pre-existing ulnar translation of the carpus in rheumatoid patients may be a contraindication for the Darrach procedure because there is a high risk of postoperative progression of ulnar translation of the carpus.26 In such patients, the Sauvé–Kapandji procedure may be preferred.27 This procedure fuses the ulnar head to the radius, and an osteotomy is performed proximal to the ulnar head to permit forearm rotation. The intact ulnar head can support the ulnar carpus to prevent its ulnar translocation. Alternatively, radiolunate or total wrist arthrodesis combined with the Darrach procedure can also be performed.28

Preoperative history and considerations Rheumatoid and non-rheumatoid patients should be considered separately because the indications, contraindications, technical concerns, and expected results following the Darrach procedure may differ. Poor outcomes are almost always related to either improper patient selection or


Sigmoid notch

Ulnar Radius

FIGURE 13.10 Osteotomy level of the ulnar head. An osteotomy of the ulna should be made at the level of the proximal margin of the sigmoid notch.

improper resection of the ulnar head.29 As mentioned earlier, failures tend to occur in younger and high-demand patients. Ulnar stump instability resulting from excessive ulnar resection is difficult to treat. Ulnar resections of >30 mm commonly result in painful snapping of the ulnar stump.24 Osteotomy of the ulna should be made at the level of the proximal margin of the sigmoid notch, which can contribute to the creation of a stable asymptomatic radioulnar pseudoarthrosis (Fig. 13.10). Another consideration for osteotomy includes the shape of the ulnar stump. If the ulna is cut transversely, it can leave a sharp edge to converge on the radius to create stress concentration.24 It is important to shape the distal ulnar stump in order to reduce stress concentration by decreasing the potential surface area for radioulnar contact. The authors usually make an oblique osteotomy that angles distally towards the ulnar styloid.

FIGURE 13.11 A skin incision is made over the ulnar head. The dotted line indicates the path of the dorsal ulnar sensory nerve, which should be carefully protected.

FIGURE 13.12 The extensor retinaculum over the ulnar head is exposed.

Operative approach The operation is performed under regional or general anesthesia with tourniquet control. The surgical approach is through a 4-cm longitudinal incision over the ulnar head (Fig. 13.11). The subcutaneous tissue is dissected just above the level of the extensor retinaculum (Fig. 13.12). Care is taken to protect the dorsal branch of the ulnar nerve. A longitudinal incision of the extensor retinaculum is made between the fifth and sixth dorsal compartments. The dorsal capsule of the DRUJ is incised longitudinally to expose the ulnar head (Fig. 13.13). This is further exposed subperiosteally just proximal to the DRUJ articulation. An oscillating saw is used to make an oblique osteotomy at the level of the proximal margin of the sigmoid notch, with the bevel of the osteotomy oriented radially and dorsally (Fig. 13.14). The distal ulnar fragment is removed by releasing the periosteum and triangular fibrocartilage complex from the ulnar head and styloid. After removal of the ulnar head

FIGURE 13.13 After incision of the extensor retinaculum and dorsal capsule of the distal radioulnar joint, the ulnar head is exposed.


FIGURE 13.14 An oblique osteotomy with the bevel oriented radially and dorsally is made using an oscillating saw.

FIGURE 13.16 Postoperative radiograph showing proper excision of the ulnar head.

FIGURE 13.15 After closing the dorsal capsule, the extensor retinaculum is repaired.

we stabilize the distal ulnar stump using a variety of techniques, including tenodesis of the distal ulnar stump using a strip of the extensor carpi ulnaris tendon.30 The authors nearly always perform the tenodesis procedure in younger, non-rheumatoid patients because instability of the ulnar stump is usually related to excessive resection of the ulnar head and can be avoided with proper osteotomy. The dorsal capsule and extensor retinaculum are repaired with 3/0 absorbable sutures (Fig. 13.15), followed by wound closure. Postoperative radiographs should show proper excision of the ulnar head (Fig. 13.16).

Postoperative care and expected outcomes A plaster sugar-tong splint is applied with the forearm in 45º supination and the wrist in the neutral position. Active full mobilization of the fingers can begin immediately after the operation. After 1 week, the sutures are removed. The

wrist is splinted in a removable Orthoplast supination splint for another 3 weeks, and finger exercises are started. After this splinting period, supervised therapy is initiated involving forearm rotation and wrist motion for the next 3 weeks. A strengthening program is initiated 7 weeks after surgery. Regardless of the underlying diagnosis, most patients achieve satisfactory relief of ulnar-sided pain and restoration of forearm rotation.21–23

Complications Ulnar stump instability, which can develop into radioulnar impingement and painful crepitus, is the most common complication after the Darrach procedure.31 A variety of soft tissue stabilization techniques have been used to reduce the instability of the ulnar stump.30 However, instability is usually related to excessive resection of the ulnar head. Postoperative ulnar translation of the carpus can be a common complication in rheumatoid patients. This problem appears to be more related to the natural history of the rheumatoid arthritis process than to the procedure itself, because postoperative ulnar translation is uncommon in non-rheumatoid patients.22 Complications such as

Surgical Procedures for the Distal Radius and Distal Radioulnar Joint 191 ulnar stump instability and weakness of grip strength may frequently be encountered in younger and high-demand patients.

CONCLUSION The VLPS has been shown to be a reliable plating system for the fixation of distal radius fractures, and enables early motion without compromising fracture reduction. Hand surgeons who treat distal radius fractures should be familiar with this technique. The Darrach procedure is still a valuable technique for treating DRUJ disorders, but should be used selectively. An understanding of proper patient selection and the operative procedure provides satisfactory outcomes in most patients.

REFERENCES 1. Chung KC, Spilson SV. The frequency and epidemiology of hand and forearm fractures in the United States. J Hand Surg [Am] 2001; 26: 908–915. 2. Rosenthal AH, Chung KC. Intrafocal pinning of distal radius fractures: a simplified approach. Ann Plast Surg 2002; 48: 593–599. 3. Margaliot Z, Haase SC, Kotsis SV, et al. A meta-analysis of outcomes of external fixation versus plate osteosynthesis for unstable distal radius fractures. J Hand Surg [Am] 2005; 30: 1185–1199. 4. Ring D, Jupiter JB, Brennwald J, et al. Prospective multicenter trial of a plate for dorsal fixation of distal radius fractures. J Hand Surg [Am] 1997; 22: 777–784. 5. Orbay JL, Fernandez DL. Volar fixation for dorsally displaced fractures of the distal radius: a preliminary report. J Hand Surg [Am] 2002; 27: 205–215. 6. Chung KC, Watt AJ, Kotsis SV, et al. Treatment of unstable distal radial fractures with the volar locking plating system. J Bone Joint Surg [Am] 2006; 88: 2687–2694. 7. Musgrave DS, Idler RS. Volar fixation of dorsally displaced distal radius fractures using the 2.4-mm locking compression plates. J Hand Surg [Am] 2005; 30: 743–749. 8. Chung KC, Squitieri L, Kim HM. A comparative outcomes study of using the volar locking plating system for distal radius fractures in both young and elderly adults. J Hand Surg [Am] (in press). 9. Amadio PC, Botte MJ. Treatment of malunion of the distal radius. Hand Clin 1987; 3: 541–561. 10. Sammer DM, Kawamura K, Chung KC. Outcomes using an internal osteotomy and distraction device for corrective osteotomy of distal radius malunions requiring correction in multiple planes. J Hand Surg [Am] 2006; 31: 1567–1577. 11. Darrach W. Anterior dislocation of the ulna. Ann Surg 1912; 56: 802–803.

12. Sauvé L, Kapandji M. Nouvelle technique de traitement chirurgical des luxations récidivantes isolées de l’extrémité inférieure du cubitus. J Chir 1936; 47: 589–594. 13. Orbay JL, Touhami A. Current concepts in volar fixed-angle fixation of unstable distal radius fractures. Clin Orthop Relat Res 2006; 445: 58–67. 14. Orbay J. Volar plate fixation of distal radius fractures. Hand Clin 2005; 21: 347–354. 15. Graff S, Jupiter J. Fracture of the distal radius: classification of treatment and indications for external fixation. Injury 1994; 25: S-D14–25. 16. Chung KC, Kotsis SV, Kim HM. Predictors of functional outcomes after surgical treatment of distal radius fractures. J Hand Surg [Am] 2007; 32: 76–83. 17. Chung KC, Petruska E. Treatment of unstable distal radial fractures with the volar locking plating system. Surgical technique. J Bone Joint Surg [Am] 2007; 89: 256–266. 18. Kotsis SV, Lau FH, Chung KC. Responsiveness of the Michigan Hand Outcomes Questionnaire and physical measurements in outcome studies of distal radius fracture treatment. J Hand Surg [Am] 2007; 32: 84–90. 19. Arora R, Lutz M, Hennerbichler A, et al. Complications following internal fixation of unstable distal radius fracture with a palmar locking-plate. J Orthop Trauma 2007; 21: 316–322. 20. Klug RA, Press CM, Gonzalez MH. Rupture of the flexor pollicis longus tendon after volar fixed-angle plating of a distal radius fracture: a case report. J Hand Surg [Am] 2007; 32: 984–988. 21. DiBenedetto MR, Lubbers LM, Coleman CR. Long-term results of the minimal resection Darrach procedure. J Hand Surg [Am] 1991; 16: 445–450. 22. Tulipan DJ, Eaton RG, Eberhart RE. The Darrach procedure defended: technique redefined and long-term follow-up. J Hand Surg [Am] 1991; 16: 438–444. 23. Posner MA, Ambrose L. Excision of the distal ulna in rheumatoid arthritis. Hand Clin 1991; 7: 383–390. 24. Garcia-Elias M. Failed ulnar head resection: prevention and treatment. J Hand Surg [Br] 2002; 27: 470–480. 25. Hagert CG. The distal radioulnar joint in relation to the whole forearm. Clin Orthop Relat Res 1992; 275: 56–64. 26. Ishikawa H, Hanyu T, Tajima T. Rheumatoid wrists treated with synovectomy of the extensor tendons and the wrist joint combined with a Darrach procedure. J Hand Surg [Am] 1992; 17: 1109–1117. 27. Millroy P, Coleman S, Ivers R. The Sauvé–Kapandji operation. Technique and results. J Hand Surg [Br] 1992; 17: 411–414. 28. Ishikawa H, Hanyu T, Saito H, Takahashi H. Limited arthrodesis for the rheumatoid wrist. J Hand Surg [Am] 1992; 17: 1103–1109. 29. Field J, Majkowski RJ, Leslie IJ. Poor results of Darrach’s procedure after wrist injuries. J Bone Joint Surg [Br] 1993; 75: 53–57. 30. Leslie BM, Carlson G, Ruby LK. Results of extensor carpi ulnaris tenodesis in the rheumatoid wrist undergoing a distal ulnar excision. J Hand Surg [Am] 1990; 15: 547–551. 31. McKee MD, Richards RR. Dynamic radio-ulnar convergence after the Darrach procedure. J Bone Joint Surg [Br] 1996; 78: 413–418.

CHAPTER

14

Tendon Transfers Neal Chen, Chai Mudgal, Jesse B. Jupiter, and David Ring

INTRODUCTION The development of tendon transfer procedures by surgeons such as Mayer, Bunnell, and Jones contributed to the growth of hand surgery as an independent discipline.1 Tendon transfers can transform a deformed and dysfunctional limb into a functional hand that contributes to basic functional tasks. The effects of nerve injury, rheumatoid arthritis, and traumatic or attritional tendon injury can in part be mitigated by appropriately selected tendon transfers. In the current era of rapid technological innovation, the techniques of tendon transfer remain useful with limited modification and are an essential tool in the hand surgeon’s armamentarium.

INDICATIONS AND CONTRAINDICATIONS Patients should satisfy all of the following criteria to be considered for tendon transfer: ● Irrecoverable loss of muscle function owing to direct injury, nerve injury, or central nervous system injury. ● Adequate joint mobility. ● Stable soft tissue envelope. ● No active infection. ● Adequate cognition and motor control. ● Adequate sensibility. ● Specific correctable functional deficit. ● Available donor tendons.

Principles Several principles guide decision making when considering tendon transfer to improve hand function. ● Appropriateness of transfer Tendon transfer is only appropriate when the function of an available donor muscle is expendable and when the donor muscle will work effectively in its new location and role. Alternatives to tendon transfer include reconstruction of existing motor units with tendon grafts, neurorrhaphy,

●

neurotization, tenodesis, arthrodesis, or free muscle transfer. Timing Patients should understand the risks and benefits of tendon transfer and have realistic expectations. Tendon transfer is considered when the skin cover is stable and mobile, the tendons and joints have adequate mobility, deformity is minimized, and potential donor muscles have been adequately rehabilitated and strengthened. In some patients with substantial scarring, a temporary silicone rod can be used to produce a smooth gliding scar route along the expected course of the transfer.4

Donor muscle characteristics Availability

The donor muscle must be expendable. A general goal is to retain one wrist flexor (preferably the flexor carpi ulnaris – FCU), one wrist extensor (preferably the extensor carpi radialis brevis – ECRB), and one extrinsic digital flexor and extensor to each finger.

Strength As a rough approximation, strength is proportional to the physiologic cross-sectional area of a muscle. A common estimate of strength is 3.65 kg/cm2 multiplied by the crosssectional area in square centimeters.2,3 The strength of a muscle to be transferred should be comparable to the strength of that to be replaced. Strength, however, is not equivalent to work capacity. Work capacity is relative to the volume and hence the mass of the muscle. The tension fraction – the relative tension generated by a muscle relative to another – has been described by a number of authors (Table 14.1).1 After transfer, the donor muscle can be expected to lose one grade of strength. Subsequent transfer of a muscle that has partially recovered from paralysis or has weakness should generally be avoided, if possible.

193

194 Hand and Upper Extremity Reconstruction What muscles work? Which muscles are available/expendable? What functions are needed? Next, an attempt is made to match available muscles with functions. Alternative tendon transfers and other possibilities such as tenodesis and arthrodesis are considered. Finally, when the optimal procedures have been selected, staging of procedures is considered to optimize rehabilitation. This is especially the case in situations when the functions needed exceed the number of donors available. For example, if the wrist is fused it eliminates the need for a donor to power the wrist, and attention may be devoted to the digits. ●

TABLE 14.1 Potential force of various muscle transfers Muscle

●

Potential force

●

●

Brachioradialis

2.0

FCU

2.0

Pronator teres

1.5

FCR, ECRL, ECRB, ECU

1.0

EDC, EIP, EDQ

0.5

EPB, PL

0.1

●

●

Amplitude Muscles can contract or lengthen approximately 40% of their resting length. Amplitude is the difference between the minimum and maximum lengths of a muscle. Amplitude is proportional to the muscle fiber length and may be approximated using the following general guidelines:4 Insertion Distal to the wrist joint (flexor carpi radiolis/ flexor carpi ulnaris) MP joint/distal thumb (extensor indicis proprius/extensor pollicis longus) flexor digitorum profundus/flexor digitorum superficialis

Amplitude 3 cm 5 cm 7 cm

The tenodesis that occurs with wrist motion can provide an additional 2.5 cm of tendon excursion. When one drops the wrist, the tenodesis effect extends the fingers. Patients use the tenodesis effect to augment inadequate finger extension caused by insufficient amplitude of the tendon transfer to the extensor mechanism.

Transfer characteristics Direction

A straight line of pull is preferred during tendon transfers. A pulley may be used to help reroute the vector of pull; however, more than one pulley is not helpful and significantly diminishes strength and excursion.

Single function/synergy Each tendon transferred should be used to perform one single task. In addition, a synergistic muscle – i.e. a muscle that usually contracts simultaneously with the muscle being reconstructed to achieve a desired function – is preferred as a donor. For example, wrist flexion is synergistic with finger extension. Therefore, transferring wrist flexors to finger extensors is synergistic, and learning to use the transfer is quite straightforward.

PREOPERATIVE HISTORY AND CONSIDERATIONS A systematic approach is used to plan tendon transfers.1 ● First the musculotendinous units are cataloged as follows:

OPERATIVE TECHNIQUES The patient is supine with the arm supported on a hand table. A tourniquet is used to limit bleeding and improve visualization and safety. A sterile tourniquet may make it easier to position and manipulate the arm.

Tendon harvest The authors prefer to harvest donor tendons by identifying the distal end of the tendon. An incision is made over the distal end and a tendon hook is passed underneath the tendon and tension applied. This should help identify the distal function of the tendon as well as its course proximally. A proximal incision is made once the course of the tendon is identified. Tension is again applied using a tendon hook, and the appropriate distal effect is sought to ensure the proper tendon is being harvested. The distal end is then released sharply with a no. 15 blade scalpel and the tendon is extracted into the proximal wound (Fig. 14.1).

Tendon passage Once a donor tendon and an attachment site have been identified and clearly dissected, a provisional traction stitch is placed at the end of the tendon. A curved or straight tendon passer is then passed subcutaneously from the recipient site to the donor site. The traction stitch is used to pass the end of the donor tendon through the tunnel and into the distal wound, where the accepting tendon lies.

Pulvertaft weave A Pulvertaft weave is a method of joining tendons used primarily for tendon mismatch.5 The larger tendon is cut into a fish-mouth shape to accept the initial pass of the smaller tendon. This is done to improve gliding characteristics and to accommodate the size mismatch. Using a tendon weaver, the surgeon passes the smaller tendon through the larger tendon and sutures it provisionally with a single stitch to set the proper tension. Once the tension is set, the end of the smaller tendon is passed through the larger tendon at a 90º angle from the previous pass, and a second stitch is placed at the tendon junction. Four passes in total are preferred. It is preferable if the tendon junction

Tendon Transfers 195

A

B

C FIGURE 14.1 Tendon harvest. A The distal end of the tendon is identified and its function is confirmed. B Tension on the tendon helps to identify its proximal course. The proximal part of the tendon is isolated in the proximal wound prior to release of the tendon distally. C After distal tendon release, the tendon is brought into the proximal wound.

is not in close proximity to the wound, although this is often unavoidable (Fig. 14.2). An alternative to an end-to-end weave is an end-to-side weave. This is performed in a similar manner to the original Pulvertaft weave, but no fish-mouth incision is made in the larger tendon.

HIGH RADIAL NERVE PALSY A patient with a high (or complete) radial nerve palsy is a good candidate for tendon transfer. The sensory deficit is not in a functional area and the function to be restored

involves a relatively unsophisticated opening of the hand and wrist. Tendon transfers for radial nerve palsy were among the earliest transfers attempted and have been performed since the early 1900s.6,7 In isolated high radial nerve palsy, all of the median and ulnar innervated wrist and digital flexors are available as donors. Reconstruction of thumb, digit, and wrist extension (hand opening) is made more feasible when all six index through small digital extensors are consolidated into one function and all three thumb motors are consolidated (Table 14.2a). In this manner, one donor will provide wrist extension, a second finger extension, and a third thumb

196 Hand and Upper Extremity Reconstruction TABLE 14.2a Radial nerve palsy

A

Functional groups to be reconstructed

What works

What is available

What is needed

Thumb extensors/abductors

PL

PL

APL EPB EPL

Wrist extensors

PT

PT

ECRL

FPL

ECRB ECU

B

Digit extensors

FDS (i, l, r, s)

FDS (m)

EIP

FCR

FDS (r)

EDC (I, l, r, s)

FCU

FCR

EDM

FCU

C

D

TABLE 14.2b Radial nerve palsy 3 cm amplitude

5 cm amplitude

7 cm amplitude

Available

Need

Available

Need

Available

FCR

ECRL

PL

EPL

FDS (m)

FCU

ECRB

FCR + tenodesis

EIP

FDS (r)

PT

ECU

FCU + tenodesis

EDC

APL

PT + tenodesis

EDQ

Need

EPB FIGURE 14.2 Pulvertaft weave: end to end. A The larger tendon is fish-mouthed to accept the smaller tendon. B The smaller tendon is passed into the fish-mouth and through the side of the tendon. A provisional stitch is placed to test the resting tension. C The smaller tendon end is passed at a 90º angle to the larger tendon as well as orthogonal to the previous pass. Further passes may be made into the larger tendon, each at 90º to the previous pass. D The fishmouth is sutured closed over the tendon.

rum superficialis (FDS) ring can be transferred to the extensor pollicis longus (EPL). The donor tendons may either be passed through the interosseous membrane or routed around the radius.

Operative technique (modified Starr transfer) extension. Amplitude and strength are considered when selecting donor muscles (Table 14.2b). Among the two most popular transfers for digit extension (flexor carpi ulnaris, FCU and flexor carpi radialis, FCR), the FCR transfer has been more popular recently because preservation of the FCU enhances power grip, which has better biomechanical advantage in ulnar deviation, and better maintains wrist flexion strength because the FCU is twice as strong as the FCR.7 Transfer of the flexor digitorum superficialis of the ring finger has provided satisfactory digital extension and can be considered as an alternative in unusual circumstances.8 In the absence of a palmaris longus (PL), the extensor pollicis longus (EPL) can be either be included with the extensor digitorum communis (EDC) tendons (low-demand hand) or the flexor digito-

Some surgeons prefer to make three separate incisions: one at the volar wrist to harvest the FCR and PL, one over the middle third of the forearm for transfer of the pronator teres, and one over the extensor surface of the wrist to tie in the FCR and PT transfers (Fig. 14.3). As an alternative, the procedure can be completed through a single slightly dorsal radial incision that curves volarwards at the wrist. Developing broad skin flaps provides access to all structures and leaves all sites of tendon insertion away from the incisions. The interval between the flexor carpi radialis and the brachioradialis is developed and the insertion of the pronator teres onto the radial diaphysis is identified by pronating the forearm. The pronator teres is mobilized and its tendon lengthened by elevating it along with a strip of periosteum to increase its effective length available for tendon repair.


Incision for pronator teres harvest

Incision for FCR and palmaris harvest

passed through the EDC and the EIP using the Pulvertaft weave. Appropriate tension is achieved when, with the wrist fully extended, full composite digital flexion is possible, and, with the wrist in neutral, the fingers will extend via a tenodesis effect. Finally, the palmaris longus is woven through the translocated EPL tendon. The target tension is such that with the wrist in extension, it is possible to flex the thumb 10– 15º at each joint and with the wrist slightly flexed, the thumb will extend easily and open the first web space. The tourniquet is released, hemostasis achieved, and the wounds are irrigated and closed. A padded dressing is applied by incorporating a long-arm splint with the wrist in about 30–40º of extension, the forearm in neutral or slight pronation, the metacarpophalangeal and interphalangeal joints straight, and the thumb abducted and straight.

Incision for transfers

FIGURE 14.3 Incisions for Starr transfer. Distal–volar incision for FCR and palmaris longus harvest, proximal–radial wound for pronator teres harvest, and dorsal incision for transfers.


●

The FCR and the palmaris longus tendons are cut at the level of the transverse wrist creases and brought proximally into the forearm. The three donor tendons in the forearm are then wrapped in moist gauze (Fig. 14.4). The third dorsal compartment is opened and the EPL is transposed dorsal to the retinaculum and radially, so that it will function as both an extensor and an abductor of the thumb. The extensor digitorum communis and the ECRB are identified and isolated in preparation for donor tendon insertion. The donor tendons are passed through subcutaneous tunnels into the dorsal wound, or directly through the wound when a single incision is used. The volar wound is closed now when three separate incisions are used. The wrist is placed in about 30–40º of extension. The appropriate tension at which to suture the donors to the tendons being reconstructed is a matter of debate, but we prefer to use just submaximal tension for radial nerve tendon transfers. In addition, some surgeons leave the original musculotendinous units intact and suture the donor in an end-to-side fashion (in case there is any chance of recovery of the original tendons); others prefer to divide the proximal recipient tendons and suture the donors in more of an end-to-end fashion. First, the pronator teres and its periosteal extension is woven through the tendon of the ECRB using a Pulvertaft weave. The wrist should rest in a position of about 20–30º of extension after the sutures are placed. Next, the EDC and the EIP are sewn together just proximal to the extensor retinaculum using 3/0 braided nonabsorbable suture to convert them into a single mass. The extensor digiti quinti (EDQ) is not included to avoid any excessive extension force on the small finger. The FCR is

●

●

The tendon of the pronator teres is short and the ease and strength of suturing are both enhanced by taking care to make a long, reliable tail of periosteum from the radius. The suture used to bind the common extensors and the extensor indicis together as a unit should be placed away from the Pulvertaft weave to maintain the mass effect and ensure transfer effectiveness. The tension of each transfer should be tested with a stay stitch prior to proceeding with the Pulvertaft weave. If necessary, forearm fascia can be harvested from the extensor muscles to augment the tendon-to-tendon junctions.

Complications The most common complication of tendon transfers for high radial nerve palsy is under- or overcorrection. Minor imperfections in tensioning are easily accommodated by wrist positioning. In fact, even the best results of transfer rely to some degree on the tenodesis effect. Problematic over- or under-tensioning can be addressed using a second operation to either lengthen or shorten the tendons in question.

Postoperative care Sutures are removed at 2 weeks. Splinting is maintained for 4–6 weeks, and then active range of motion and retraining are begun.

LOW RADIAL NERVE PALSY Lower radial nerve palsies can present in two forms. In the first, the extensor carpi radialis longus (ECRL) is functional because the injury is distal to the ECRL nerve branch, which is given off proximal to the posterior interosseous nerve; however, the ECRB, extensor carpi ulnaris (ECU),


A

C

B

D

FIGURE 14.4 Tendon transfers to reconstruct radial nerve dysfunction. A From left to right the pronator teres with periosteal extension, flexor carpi radialis, and palmaris longus have been released and brought into the proximal forearm wound. B The recipient tendons are isolated in a dorsal wound. The extensor digitorum communis is in the Allis clamp, the rerouted extensor pollicis longus is in the tendon hook, and the extensor carpi radialis brevis is in the inferior portion of the wound. C The rerouted pronator teres is sutured to the extensor carpi radialis brevis using a Pulvertaft weave. D The rerouted flexor carpi radialis is sutured to the extensor digitorum communis using a Pulvertaft weave.

and the distal extensors are paralyzed because of nerve injury distal to the ECRL nerve branch. In this case, the FCR is transferred to the EDC and the palmaris longus is attached to the EPL, but because the ECRL is functioning it is sutured to the ECRB, rather than sacrificing the pronator quadratus. In the second form, the muscles proximal to the EIP and EDQ function, but the EDC, EPL, EPB, and APL are paralyzed. The EDC of the middle finger is sutured side-to-side to the EIP, and the EDC of the ring finger is sutured side-to-side to the EDQ. The palmaris longus is transferred to the EPL.

LOW MEDIAN NERVE PALSY (OPPOSITION TRANSFER) Thumb opposition is defined as ‘when the thumb pad is diametrically opposed to the distal pad of the middle finger.’1

Thumb opposition involves motions of palmar abduction, flexion, and thumb pronation. Opposition is accomplished by the intrinsic muscles of the thumb, which place the thumb in a position to allow grasp, in concert with the flexor pollicis longus. Bunnell9 emphasized the restoration of two functions when performing a tendon transfer for thumb opposition: the thumb should be pulled in an appropriate direction of palmar abduction and flexion; and pronation of the thumb. A number of tendons have been used for opposition transfer (Table 14.3), but four are in common use: the flexor digitorum superficialis of the ring finger, the palmaris longus with a strip of palmar fascia (Camitz), abductor digiti quinti, and extensor indicis proprius. Each transfer has advantages and disadvantages. Transfer of the FDS to the ring finger provides a strong muscle with great excursion, but requires the construction


E

G

FIGURE 14.4, cont’d E The palmaris longus is sutured to the transposed extensor pollicis longus using a Pulvertaft weave. F The intraoperative resting tension with slight wrist extension. G The metacarpophalangeal joints are able to flex with greater wrist extension.

F

of a pulley to obtain an appropriate vector force. It is most commonly used for patients with low median nerve palsy without scarring at the wrist that will impede tendon excursion or loss of extrinsic finger flexors. Use of the palmaris longus (Camitz transfer) does not create additional functional loss, but the palmaris longus is not a constant anatomic structure and its transferred function relies heavily on the tenodesis effect. The prevalence of palmaris longus absence ranges from 3% to 24%.10,11 It is used primarily for the reconstruction of thumb opposition in the setting of advanced carpal tunnel syndrome with severe thenar wasting. The Camitz transfer serves more in the capacity of an abductorplasty. The ADQ transfer can have a nice aesthetic appearance in its recreation of a thenar eminence, but it has a short excursion and this muscle transfer may have the attendant risks of denervation and ischemic necrosis. It is most commonly used in the pediatric setting for hypoplastic thumb reconstruction.12 The EIP is most useful in combined median and ulnar nerve palsies, but carries the risk of incomplete index finger

extension after transfer.13 To avoid extensor lag after EIP transfer, a number of authors have emphasized the importance of preserving the dorsal hood during harvest.14,15 This tendon is best harvested proximal to the hood. To improve thumb pronation, some surgeons recommend splitting the tendon attachments or looping the distal tendon through the dorsal extensor hood of the thumb metacarpophalangeal joint.9,16 Others use biomechanical data to support the use of a single attachment to the APB, except in the setting of combined nerve palsies.17

Operative technique: FDS ring or Bunnell opposition transfer For the FDS ring (Bunnell) transfer, the tendon is detached through a skin incision over the metacarpal head by releasing the A1 pulley and retrieving the tendon using a 2 cm incision over the volar forearm just ulnar to the palmaris longus tendon. A third 2 cm incision is made along the ulnar border of the wrist at the junction of the glabrous and non-glabrous skin. The tendon is then passed around

200 Hand and Upper Extremity Reconstruction TABLE 14.3 Low median nerve palsy What works

What is available

What is needed

PT

PT

APB

FCR

FCR

OP

PL

PL

FPL

FPL

FDS (I)

FDS (I)

FDS (m)

FDS (m)

FDS (r)

FDS (r)

FDS (s)

FDS (s)

FCU

FCU

APL

Operative technique: pamaris longus or Camitz opposition transfer A palmaris longus opposition (Camitz) transfer is performed through an extended carpal tunnel release incision that crosses the transverse wrist creases obliquely and extends to the distal palmar crease. The palmaris longus is identified in the proximal part of the incision and a strip of palmar fascia is raised to extend the working length of the tendon. The palmaris longus is carefully dissected with an extension of the palmar fascia. The fascia is raised as a strip about 4–5 cm wide. Because the palmar fascia is thin, it can be folded on itself to give it substance for later repair. However, undermining of the skin should be kept to a minimum to avoid a postoperative hematoma and superficial skin necrosis. Release of the transverse carpal ligament is often performed because this procedure is indicated for long-standing carpal tunnel syndrome with concomitant thenar atrophy. The palmaris longus tendon is then passed through a subcutaneous tunnel to an incision at the thumb metacarpophalangeal (MP) flexion crease and sutured to the tendon of the abductor pollicis brevis. Tensioning and postoperative management are similar to those described for the Bunnell FDS transfer (Fig. 14.6).

EPB

EPB

ECRL

ECRL

ECRB

ECRB

EPL

EPL

EIP

EIP

EDC

EDC

Operative technique: EIP opposition transfer

EDM

EDM

ECU

ECU

ADQ

ADQ

A longitudinal incision is made over the dorsum of the index MP joint. The ulnar tendon is the extensor indicis proprius. Tension is placed on the EIP and the proximal end of the tendon is identified in a separate incision at the level of the wrist. The EIP is released proximal to the dorsal hood of the index finger and drawn into the proximal wound. The EIP tendon is then passed subcutaneously under a 2 cm incision at the ulnar border of the palm in the junction of the glabrous and non-glabrous skin. From here it is passed subcutaneously through the palm into a small incision at the MP flexion crease and sutured to the abductor pollicis brevis (APB) insertion. Tensioning and postoperative management are as described for the other transfers.

FDQ ODQ Interossei FPB AddP

the flexor carpi ulnaris, using the pisiform as a pulley. An alternative is to loop a slip of the FCU tendon for use as a pulley. Finally, a 3 cm incision is made along the radial border of the thumb and the abductor pollicis brevis tendon is identified. A snap is used to make a subcutaneous tunnel connecting this incision to the previous incision, and the tendon is withdrawn and sutured to the abductor pollicis brevis tendon. With appropriate resting tension, the thumb should be in full opposition when the wrist is fully extended and wrist extension should not be limited. After wound closure, a splint is applied that immobilizes the wrist in 30º of extension with the thumb in full opposition. The splint is removed after 4 weeks and active motion is initiated while using a protective long opponens splint for another 4 weeks (Fig. 14.5).

Operative technique: abductor digiti quinti or Huber transfer A longitudinal incision along the junction of the glabrous and non-glabrous skin is made extending from the pisiform to the PIP joint of the small finger. The tendon of abductor digiti quinti is identified and released and the remainder of the muscle is freed from distal to proximal. A second incision is made along the MP flexion crease of the thumb and the APB is identified. A curved hemostat is tunneled subcutaneously from the radial wound into the ulnar wound and the ADQ is passed to the thumb wound. The donor tendon is stitched to its recipient site. A number of modifications of the Huber transfer have been proposed, including a neurovascular island pedicle or fractionated lengthening in order to avoid ulnar nerve compression at Guyon’s canal18 (Fig. 14.7).


C A

D B FIGURE 14.5 Transfer of the flexor digitorum superficialis to the ring finger (FDS ring) to restore opposition. A The FDS ring has been detached distally near the A1 pulley and retracted into a volar forearm wound. B The FDS ring is passed around the flexor carpi ulnaris insertion into the pisiform. A subcutaneous tunnel has been created. C After passage of the FDS ring tendon through the subcutaneous tunnel, it is woven through the abductor pollicis brevis tendon. D The transfer achieves a resting position with some palmar abduction.


●

●

●

Before performing an opponensplasty, it is critical to obtain a radiograph of the thumb to confirm the absence of advanced degenerative disease of the carpometacarpal (CMC) joint, which, if present and if associated with significant stiffness of the CMC, can undermine the success of any opponensplasty. Problems with rotation of the distal FCU pulley can be avoided by fashioning a pulley using a slip of FCU rather than the entire tendon. In more complex cases, such as combined nerve palsies or brachial plexus injury, the distal end of the tendon may need to be sutured to the dorsal hood to provide more opposition. During tension trials, if the MP joint flexes with the wrist extended, the insertion site should be moved dorsally to add more extension force to the MP joint; if the MP joint hyperextends, the insertion should be moved volarly.

Complications Preoperative adduction contracture can limit the effectiveness of an opposition transfer and should be treated beforehand. The use of an FCU pulley may lead to scar formation and adhesions, and if this occurs, rerouting around the FCU is recommended. Problems with the donor finger may also be encountered, in that a proximal interphalangeal (PIP) joint flexion contracture or a swan-neck deformity may arise because the FDS is detached.

HIGH MEDIAN NERVE PALSY In high median nerve palsy the FDP to the index, and perhaps to the long, finger is paralyzed. The paralyzed muscles are sutured side-to-side with an adjacent functioning profundus tendon. The brachioradialis is transferred to


A

D

B

E

F C FIGURE 14.6 Transfer of the palmaris longus to restore opposition in a patient with advanced carpal tunnel syndrome (Camitz transfer). A The hand is positioned using a lead hand and the incisions are planned. B The palmaris longus tendon is identified and lengthened with a strip of palmar fascia. C A subcutaneous tunnel is created to the level of the thumb metacarpophalangeal joint. D The palmaris longus is brought through the tunnel using a curved hemostat. E The tendon is then woven and sutured to the abductor pollicis brevis tendon. F The tension creates a resting position in palmar abduction.


APB

FIGURE 14.7 Transfer of the abductor digiti minimi for restoration of opposition (Huber transfer).

restore FPL function. Because the FDS ring is not available for transfer and the palmaris longus is paralyzed, the EIP is used for opposition transfer (Fig. 14.8).

EIP

FDP Brachioradialis FPL

LOW ULNAR NERVE PALSY Low ulnar nerve palsy results in two major deficits: weakness of power pinch, and intrinsic muscle dysfunction. Smith categorized intrinsic dysfunction in low ulnar nerve palsy into four groups: deformity, weakened grip, asynchronous motion, and loss of lateral finger mobility.1 Loss of intrinsic function to counterbalance the extrinsic extensors leads to clawing as well as weakness of grip; simultaneous MP flexion and IP extension is lost, resulting in inability to grasp objects such as oranges or apples, or perform pulpto-pulp pinch. Loss of lateral finger motion also restricts subtle digit movements that are used in playing musical instruments, or the facile use of a keyboard. Brand3 estimated that 75% of power pinch is derived from the adductor pollicis and the first dorsal interosseus. In the absence of adductor pollicis function, the flexor pollicis longus is used for power pinch, resulting in Froment’s sign (Fig. 14.9). Over time, as the FPL is used for pinch, the volar plate of the MP joint becomes lax and Jeanne’s sign – MP hyperextension with pinch – appears.19,20 A number of tendons can be considered for transfer to restore power pinch21 (Table 14.4). The two most commonly used transfers to reconstruct the function of the adductor pollicis are the ECRB rerouted through the interosseous membrane,22 and transfer of the flexor digitorum superficialis of the ring or long finger to the adductor tendon.23 Many aspects of intrinsic dysfunction can be addressed with tendon transfer or tenodesis procedures (Table 14.4). The variety of procedures can be divided into the following groups: non-tenodesis procedures to prevent index through small finger MP hyperextension; tenodesis to prevent MP

FIGURE 14.8 Transfer for high median nerve palsy. Brachioradialis to flexor pollicis longus; extensor indicis proprius to abductor pollicis brevis; side to side of flexor digitorum profundus index and middle.

FIGURE 14.9 Froment’s sign.

204 Hand and Upper Extremity Reconstruction TABLE 14.4 Ulnar nerve palsy Problem

Options for treatment

Clawing deformity and asynchronous motion

Lumbrical bar splint MP volar capsulorrhaphy (Zancolli) Dorsal bone block Pulley advancement Tendon grafts from dorsal carpal ligaments to lateral bands (Fowler tenodesis)

Weakness of grip, clawing, and asynchronous motion

FDS to intrinsic apparatus (Stiles–Bunnell transfer) FDS lasso to annular pulley (Zancolli) FCR to intrinsic apparatus ECRB with plantaris graft to lateral bands (Brand or palmaris longus)

Weakness of thumb adduction

ECRB to adductor pollicis FDS ring to adductor pollicis EIP to first dorsal interosseus Accessory APL to first dorsal interosseus

hyperextension; tenodesis linking MP and PIP extension; and tenodesis linking MP flexion and PIP extension with wrist flexion. The effective function of tendon transfers depends on the structure to which the transfer is attached. When the tenodesis extends from a point distal to the wrist to the proximal phalanx, MP hyperextension occurs. When the tenodesis extends from a point distal to the wrist and is attached to the lateral band, linked MP and PIP extension occurs. When the tenodesis extends from a point proximal to the wrist and extends to the proximal phalanx, linked MP flexion and PIP extension is produced.1 Numerous authors have espoused different methods to restore intrinsic function.18,19,24–27 Although each patient should be considered individually, our favored techniques include transfer of the FDS ring to the adductor pollicis, accessory abductor pollicis longus to the first dorsal interosseous, and transfer of the ECRB to address clawing and improve pinch strength.

Operative technique

Brand transfer and FDS/APL for power pinch A transverse incision proximal to the dorsal extensor retinaculum extending from the first dorsal compartment to the third dorsal compartment is made. The ECRB attachment to the third metacarpal and accessory slip of the abductor pollicis longus (APL) is identified. The accessory APL is usually the most volar in the cluster of tendons in the first dorsal compartment. A second, 5 cm transverse incision is made at the base of the intermetacarpal spaces. The ECRB attachment is identified and the ECRB is released and drawn into the proximal wound. A 5 cm incision is made on the lateral border of the ankle centered between the lateral malleolus and the Achil-

les tendon, with careful attention to avoid the sural nerve. The plantaris tendon is identified, released distally, and tagged with a 3/0 braided, non-absorbable suture for handling. A closed tendon stripper is run along the tendon and the plantaris is harvested. The plantaris graft is used for two portions of the operation: to augment the adductorplasty and to use for clawing control. A portion of the graft is cut at a length adequate to span the APL to the first dorsal interosseous tendon. This tendon segment is saved in a wet sponge. The remaining plantaris tendon is used as a four-tailed graft. The central 3 cm segment will be used as an anchor to the ECRB and preserved. The ends of the tendon are split longitudinally through the midline to create four ‘tails’ that will be individually sutured to the interossei distally (Fig. 14.10). The proximal portions of the interossei are excised through the incision at the metacarpal bases and a radial incision is made at the junction of the glabrous and nonglabrous skin along each finger. A tail of the plantaris graft is passed through the interspace, volar to the deep transverse metacarpal ligament, and then attached to the radial lateral band using 4/0 Ethibond suture in a Pulvertaft weave at the level of the transverse fibers. If a Pulvertaft weave is not possible because of limited graft excursion or tendon thickness, they may be sutured end to end or side to side if necessary. The proximal end of the graft is passed subcutaneously into the proximal wound where the ECRB tendon lies, and the central, unsplit portion is secured to the ECRB (Fig. 14.10). A 3 cm incision centered along the ulnar thumb MP joint is made overlying the adductor aponeurosis. An incision in line with the distal palmar crease is made overlying the ring metacarpal. The ring superficialis is identified and transected as the ring finger is held flexed. A subcutaneous tunnel is made by passing a curved hemostat from the thumb wound over the palmar fascia and exiting through the volar ring finger wound. The superficialis tendon is drawn through the subcutaneous tunnel and secured to the tendon of the adductor pollicis using a 3/0 Ethibond suture weave (Fig. 14.11A). An incision is made at the base of the radial side of the wrist at the junction of the glabrous and non-glabrous skin. The accessory APL is identified and transected at its insertion at the base of the trapezium or scaphoid. This accessory APL slip is withdrawn proximally and the plantaris graft is interwoven with it. A subcutaneous tunnel is created from the dorsoradial index finger wound to the proximal wound. The APL–tendon graft complex is then drawn into the distal wound and interwoven into the tendon of the first dorsal interosseous tendon (Fig. 14.11B). After wound closure and dressing, a splint is applied with the wrist in 30º of dorsiflexion and the MP joints in 40º of flexion. A separate thumb spica is applied to hold the thumb at full opposition. The splint is maintained postoperatively for 4 weeks, after which time a lumbrical bar splint with a thumb spica extension is used for protection, and active range of motion is initiated.


Incision to release ECRB from base of metacarpal Incision to harvest ECRB

Each limb of plantaris graft is passed through intermetatarsal space

A

Plantaris graft

B D

Each limb of plantaris graft sutured to radial lateral band

Plantaris graft sutured to end of ECRB; passed through substance of ECRB

C

E

Plantaris graft passed palmar to transverse metacarpal ligament

FIGURE 14.10 Brand transfer. A Harvest of ECRB from base of third metacarpal. B After harvest of the plantaris tendon, the ends are split to form four tails. C The plantaris tendon is attached to the end of the ECRB. D Each limb is passed underneath the transverse metatarsal ligament on the radial side of each digit and E attached to the lateral band.


G

F

FIGURE 14.10, cont’d F The plantaris tendon has been harvested with a tendon stripper. G The tendon graft is split into four strips to connect the extensor carpi radialis brevis with the radial lateral band of index through small fingers. Prepared extensor indicis pollicis and flexor digitorum superficial ring transfers are also seen.

Inserted into adductor pollicis Woven into first dorsal interosseus muscle

FDS ring tunnelled over palmar fascia

Plantaris graft

Accessory APL

A

B

FIGURE 14.11 Transfers for power pinch. A The FDS ring is transferred over the palmar fascia and inserted into the adductor pollicis. B Accessory dorsal interosseus and a graft is transferred into the first dorsal interosseus.

Tendon Transfers 207 Optimizing outcomes ●

●

●

Tensioning of the four-tailed graft is difficult and should be performed with the wrist in neutral. The ring and little fingers should flex to approximately 40º, whereas the index and middle fingers should flex to approximately 30º. The superficialis tendon should be sutured with the thumb MP joint flexed and fully adducted. With wrist dorsiflexion, the thumb should adduct against the palm. The palmaris graft from the accessory APL should be sutured to the tendon of the first dorsal interosseous tendon with the index finger fully adducted. When the wrist is ulnarly deviated, the index finger should abduct.

Complications The Andre-Thomas sign describes flexion of the wrist with attempted IP extension.28 When the ECRB is transferred there is a loss of wrist extensor power. Subsequently, if there is persistent asynchrony of digital flexion, the wrist flexion that is seen with the Andre-Thomas sign may actually be exacerbated as the patient continues to try to compensate. There is the potential for multiple tendon grafts to be needed if one plantaris tendon is insufficient. An accessory APL is present in 90% of the population; however, in the event that the APL is not present, the surgeon should be prepared to perform an EIP transfer if needed. Finally, with superficialis harvest for opponensplasty, PIP flexion deformity or hyperextension may occur.

CONCLUSIONS It is important for a hand surgeon to be familiar with tendon transfers. Over the past century, the diverse techniques have converged into a set of reliable, reproducible transfers that can be applied to a majority of the functional deficits encountered in practice. Knowledge of the various transfer options can be useful in complex or unusual circumstances and combined nerve palsies.

REFERENCES 1. Smith RJ. Tendon transfers of the hand and forearm. Boston: Little, Brown, 1987. 2. von Recklinghausen H. Gliedermechanik und Lahmungsprosthesen. Berlin: Springer Verlag, 1920.

3. Brand PW. Clinical mechanics of the hand. St Louis: CV Mosby, 1985; 23. 4. Smith RJ. Indications for tendon transfers to the hand. Hand Clin 1986; 2: 235–237. 5. Pulvertaft RG. Tendon grafts for flexor tendon injuries in the fingers and thumb. J Bone Joint Surg 1956; 38B: 175–194. 6. Starr CL. Army experiences with tendon transference. J Bone Joint Surg 1922; 20: 3–21. 7. Zachary RB. Tendon transplantation for radial paralysis. Br J Surg 1946; 33:358–364. 8. Chuinard RG, Boyes JH, Stark HH, et al. Tendon transfers for radial nerve palsy: Use of superficialis tendons for digital extension. J Hand Surg 1978; 3: 560–570. 9. Bunnell S. Opposition of the thumb. J Bone Joint Surg 1938; 20:269–284. 10. Sebastin MJ, Puhaindran ME, Lim AY, et al. The prevalence of absence of the palmaris longus – a study in a Chinese population and a review of the literature. J Hand Surg 2003; 30: 525–527. 11. Troha F, Baibak GJ, Kelleher JC. Frequency of the palmaris longus tendon in North American Caucasians. Ann Plast Surg 1990; 25: 477–478. 12. Wissinger HA, Singsen EG. Abductor digiti quinti opponensplasty. J Bone Joint Surg 1977; 59A: 895–898. 13. Burkhalter W, Christensen RC, Brown P. Estensor indicis proprius opponensplasty. J Bone Joint Surg 1973; 55A: 725–732. 14. Noorda RJP, Havge JJ, deGroot PJM, et al. Index finger extension and strength after extensor indicis proprius transfer. J Hand Surg 1994; 19A: 844–849. 15. Browne EZ, Teavue MA, Snyder CC. Prevention of extensor lag after indicis proprius tendon transfer. J Hand Surg 1979; 4: 168–172. 16. Riordan DC. Surgery of the paralytic hand. Instructional Course Lectures 1959; 16: 79–90. 17. Cooney WP, Linscheid RL, An KN. Opposition of the thumb: An anatomic and biomechanical study of tendon transfers. J Hand Surg 1984; 9A: 777–786. 18. Cawrse MH, Sammut D. A modification in technique of abductor digiti minimi (Huber) opponensplasty. J Hand Surg 2003; 28B: 233–237. 19. Froment J. La paralysie de l’adducteur du pouce et le signe de le prehension. Rev Neurol (Paris) 1914; 28. 20. Jeanne M. La deformation du pouce dans la paralysie cubitale. Bull Mem Soc Chir 1915; 41: 703. 21. Goldfarb CA, Stern PJ. Low ulnar nerve palsy. J Am Soc Surg Hand 2003; 3: 14–26. 22. Smith RJ. Extensor carpi radialis brevis tendon transfer for thumb adduction – A study of power pinch. J Hand Surg 1983; 8: 4–15. 23. Hamlin C, Littler JW. Restoration of power pinch. J Hand Surg 1980; 5: 396–401. 24. Burkhalter WE, Strait JL. Metacarpophalangeal flexor replacement for intrinsic paralysis. J Bone Joint Surg 1973; 55A:1667–1676. 25. Brand PW. Tendon grafting. J Bone Joint Surg 1961; 43B: 444–453. 26. Zancolli EA. Structural and dynamic bases of hand surgery. Philadelphia: JB Lippincott, 1968. 27. Leddy JP, Stark HH, Ashworth CR, et al. Capsulodesis and pulley advancement for the correction of claw-finger deformity. J Bone Joint Surg 54A: 1465–1471. 28. Andre-Thomas T. Le tonus du poignet dans la paralysie du nerf cubital. Paris Med 1917; 25: 473.

CHAPTER

Techniques for Treating Finger Infections

15

Loree Kalliainen

INTRODUCTION Finger infections are common. The incidence is probably underestimated because many are treated using basic wound care by patients and by physicians other than hand surgeons. This chapter focuses on the evaluation and management of serious acute finger infections that involve several tissue layers and spread along planes or invade into joint spaces. The etiology of finger infections is most commonly related to penetrating injuries (e.g., human or animal bites, deep space penetration with contaminated items, or retained foreign objects), but hand and finger infections may also be associated with crush injuries, abrasions, hematogenous spread, or systemic conditions such as tuberculosis, diabetes, and renal transplantation.1–7 The introduction of contaminated agents into a closed space, combined with inadequate cleansing, leads to an ideal opportunity for the development of infection. For patients with inadequate host defenses, the risk of infection is likely to increase.7–9 Up to 80% of finger infections are caused by Staphylococcus aureus.10–15 If the patient is immunocompromised, the infections are more likely to be polymicrobial, and chronic infections may be due to mycobacteria or other uncommon organisms.1,4,7,16 The outcome of finger infections is poor when treatment is delayed.1,7,13,17–21

INDICATIONS AND CONTRAINDICATIONS Summary: Indications for surgical management of finger infections Indications ● Infection that has not responded to antibiotics within 24 hours ● Infection that is showing signs of progression despite antibiotics ● Joint space infections

● ● ● ●

Grossly contaminated wounds with retained foreign objects Spontaneous drainage of purulence through the skin Infection associated with signs of systemic illness Immunocompromised patient

Contraindications Cellulitis without abscess formation ● Herpetic whitlow ●

In the author’s experience, by the time a hand surgery consultation is requested for a finger infection, that infection can rarely be managed by oral antibiotics alone. A brief course of intravenous antibiotics may occasionally be successful, but operative intervention should not be delayed if the infection does not respond within 12–24 hours of intravenous antibiotic treatment. Drainage of infection should be performed if there is a deep abscess or rapidly spreading infection, concern for septic arthritis, or pyogenic flexor tenosynovitis. The threshold for surgery may also be lowered for patients with peripheral neuropathy who have a diminished pain response to infection, immunosuppression, or who are unable to participate in a physical examination because of poor mental status or advanced age. The most common organism to cause hand infections is Staphylococcus aureus, and, alarmingly, the incidence of methicillin-resistant S. aureus (MRSA) has increased to 40–50% of community-acquired Staphylococcus infections. Vancomycin, gentamicin, and trimethoprim/sulfamethoxazole currently have a high degree of efficacy in the treatment of MRSA, but individual surgeons should consult their institution’s annual antimicrobial profile.10,11 Other common organisms causing finger infections are Streptococcus spp., Pseudomonas aeruginosa, Serratia spp., Gramnegative rods, Pasteurella multocida, Eikenella corrodens, and mycobacteria.13–15

209

210 Hand and Upper Extremity Reconstruction Surgical exploration should be undertaken if the infection does not improve after 24 hours of parenteral antibiotics, or if there are signs of progression. Postoperatively, parenteral antibiotics can be continued for 1–3 days. If there is no improvement within 2 days, a return to the operating room should be planned for re-exploration.22 Once all purulence has been drained, necrotic tissue debrided, and the infection is resolving, the antibiotics may be changed to an oral form. Deeper infections and joint infections should be treated for 10–14 days. A shorter course (5–7 days) may be appropriate for more superficial infections.1,7,13,20 Patients who are severely immunocompromised and who have complex finger infections may need a protracted course of parenteral antibiotics, and an infectious disease consultation may be beneficial. Purulent or suppurative flexor tenosynovitis is diagnosed by the presence of Kanavel’s signs. First described in 1912, the four signs are fusiform digital swelling, flexed posture of the digit, pain with passive extension of the digit, and pain with palpation over the flexor sheath (Fig. 15.1).14 If three or four signs are present, there is a strong likelihood that there is purulence in the flexor tendon sheath.23 Septic arthritis is characterized by pain, edema, and reduced motion. The digit may be subconsciously held by the patient in a flexed posture to minimize pain. On physi-

cal examination there will be extreme pain with axial loading of the joint, in addition to the signs above. The erythrocyte sedimentation rate and C-reactive protein are generally elevated, but the white blood count is elevated less than 50% of the time. Acutely, the X-ray will generally be unremarkable, and obvious bone changes consistent with joint destruction predict a poorer outcome.13,18,24 This is a surgical emergency because retained purulent material within the joint can cause destruction of the articular cartilage in less than a day.13,24 Joint infection can also be caused by hematologic seeding, and a recent history of invasive procedures such as colonoscopy might be revealing.24 Infections can be confused with other inflammatory processes such as gout, but it is safer to explore an uninfected joint than risk the problems associated with joint destruction in an untreated septic joint. Paronychia and felons are the most commonly seen finger infections.25 When they are detected early, treatment is associated with rapid resolution and minimal functional impairment. If treatment is delayed, the infections may be associated with tissue loss, osteomyelitis, flexor tenosynovitis, and septic arthritis. A paronychia is related to loss of integrity between the nail and the nail fold by the inoculation of bacteria. The presentation ranges from cellulitis and edema of the paronychium (the nail folds lateral and medial to the nail plate) to abscess beneath the finger nail (Fig. 15.2). If there is no purulence below the nail, and no ‘pointing’ of abscess or purulence that is beginning to ‘point’ (whitish discoloration with thinning of the skin), nonoperative care with warm water soaks and oral antibiotics should be adequate. In the presence of purulence, operative management is indicated and the lateral 3–4 mm of the nail plate may need to be elevated and removed. Felons are closed space infections of the volar pads of the thumb or fingers. They are diagnosed by erythema and edema limited to the distal phalanx, occasional ‘pointing’ of abscess, increasing pain, and a history of a puncture or abrasion in a dirty environment. Depending on the size of the underlying abscess, there may be a palpable area of fluid.12,15,18

FIGURE 15.1 The middle finger displaying three of Kanavel’s signs: fusiform swelling, erythema, and flexed posture.

FIGURE 15.2 Ring finger showing a paronychia with a subungual abscess.

Techniques for Treating Finger Infections 211 Immunocompromised patients are at greater risk for developing finger infections. The threshold for surgical intervention should be lowered in these patients, and multiple debridements and prolonged courses of antibiotics may be needed to clear the infection.7,21,24 Contraindications to surgical exploration are few. Cellulitis without suspicion of underlying purulence should be treated with a course of antibiotics. It is important to remember that the dorsal aspect of the hand can become quite edematous without underlying abscess. Abscesses may track in a volar to dorsal direction, but this is generally accompanied by tenderness and discoloration and may be associated with spontaneous drainage through the thinner dorsal skin (Fig. 15.3A–C). Herpetic whitlows are often seen on the fingertips. They may be preceded by a tingling or burning prodrome, may be associated with erythema and edema in addition to small vesicles, and may be associated with intense pain. The edema is less pronounced than is seen with felons (Fig. 15.4). Incisions should not be made into herpetic lesions because systemic spread may occur.15

A

PREOPERATIVE HISTORY AND CONSIDERATIONS As with any injury, it is important to obtain a thorough history from the patient. Important information includes the position of the hand during the injury, whether the injury was penetrating or blunt, the environment in which the injury occurred, and whether a relatively clean instrument or a dirty one was involved. The presence of foreign bodies should always be considered, especially in wounds that are not healing as rapidly as expected. Pieces of plant material, glass, metal, fabric, and animal teeth are easily missed in initial examinations of wounds, especially if the wound is extensive. If there is a possibility that a radio-opaque object was left in the wound, X-rays in three planes should be obtained. If the wound is not healing, and the mechanism of injury involves organic matter or glass, an MRI or ultrasound may be indicated,26,27 but in these cases it may be most reasonable simply to explore the wound if the problem is well localized. In patients who have no history of a penetrating injury, the history should focus on other major medical problems or potential sources of hematogenous spread. If surgery is performed, intraoperative cultures of tissue or purulent matter should be sent for Gram stain, culture, and sensitivities. Tissue and abscess contents are preferable to wound swabs for accurate diagnosis.28 The microbiology laboratory should be contacted if there are concerns for the presence of unusual organisms such as mycobacteria or fungi, so that appropriate culture media can be used.

OPERATIVE APPROACHES Purulent flexor tenosynovitis Anatomy

Purulent flexor tenosynovitis (also called suppurative tenosynovitis) is caused by inoculation of bacteria into the flexor

B

C FIGURE 15.3 A The middle finger showing a dorsal abscess that is related to superficial trauma. B The hemostat is tracking the subcutaneous plane from dorsal to volar. C The volar incision was extended in a Bruner fashion to follow the path of purulence along the flexor sheath.


A

B FIGURE 15.4 Healing herpetic whitlow lesions. 14

tendon sheath. Infections of the tendon sheath may also be chronic and associated with mycobacteria.16 The sheath is comprised of two layers: an inner visceral layer and an outer parietal layer. It extends along the flexor tendons from the base of the distal phalanx to a level just proximal to the metacarpophalangeal joint. The flexor sheath of the small finger is usually associated with the ulnar bursa, which extends through the palm and carpal tunnel just proximal to the transverse carpal ligament. The ulnar bursa also encloses the other flexor tendons in the mid and proximal palm, and it may communicate with the radial bursa, which extends along the flexor pollicis longus tendon. This association may allow infections to track between fingers, and a careful physical examination should document the involvement of areas other than the obviously involved digit.1,14 The flexor tendon sheath is a closed space containing protein-rich nutrient synovial fluid that promotes bacterial growth. If bacteria growth cannot extrude toward the skin, the abscess tracks along the sheath proximally into the palm and wrist. As is generally good practice with the hand examination, moving toward the point of maximal pain to determine the extent of the infection minimizes pain and anxiety. For infection that has been present without

FIGURE 15.5 A This is a woman with long-standing diabetes and a fingertip ulcer with purulent discharge. The finger was notable for fusiform swelling, erythema, tenderness, and the inability to flex. B Exploration revealed spontaneous rupture of the flexor tendons. The finger was amputated.

treatment for more than a few days, the patient must be informed of the possibility of rupture of the flexor tendon. Elevated pressure in digits with purulent flexor tenosynovitis may be associated with tissue damage.17 Depending on the situation, tendon rupture may necessitate delayed multistage reconstruction or amputation of the digit (Fig. 15.5A,B). The outcome of tendon reconstruction is not good if infection-associated tendon rupture has occurred.

Minimal volar approach The author’s preferred approach to a straightforward case of purulent flexor tenosynovitis is via a minimal volar approach under conscious sedation in the operating room.19,22 Wrist and digital blocks are performed with 7– 10 mL of a 1 : 1 mix of lidocaine and bupivacaine with epinephrine prior to skin cleansing. The arm is elevated above the heart, and pressure is held over the radial and ulnar arteries for 2 minutes. A non-sterile proximal forearm

Techniques for Treating Finger Infections 213 or upper arm tourniquet is then inflated. Loupe magnification is recommended. The tendon sheath and tendon are exposed at the level of the distal interphalangeal (DIP) joint via a transverse incision, and at the level of the A1 pulley in the distal palm via a longitudinal incision. The distal incision should be just through the dermis laterally and medially, and fine scissors are used to spread the soft tissue and expose the tendon sheath. Care should be taken to avoid transecting the terminal branches of the digital nerves. If the inciting wound is over the volar proximal phalanx and the distal aspect of the finger is not grossly involved, the distal incision may be made at the level of the proximal interphalangeal (PIP) joint. When the tendon sheath is opened, any purulent matter or cloudy fluid should be cultured for aerobes, anaerobes, and special organisms (if indicated). The proximal incision should be made over the A1 pulley at the level of the metacarpal head as for a trigger finger release. The author prefers longitudinal incisions because they readily allow the extensile exposure. Senn retractors are used to expose the tendon sheath and protect the neurovascular bundles. The A1 pulley is incised with a no. 15 blade and divided with small tissue scissors. A small pediatric feeding tube is passed into the tendon sheath in a proximal to distal direction at the level of the A1 pulley. It can be challenging to insert the tube into the sheath past the level of the PIP.29 The tube can be passed along the side of the flexor digitorum profundus. Gently irrigate the tube with sterile saline. When fluid flows out of the DIP-level incision, the tube is in an appropriate position (Fig. 15.6A,B). Irrigate the sheath until the fluid is clear, and attach the tube to a bag of injectable sterile saline marked clearly as to its use. If the preoperative examination reveals pain and swelling in the volar wrist, or if milking the sheath from proximal to distal in the hand expresses cloudy fluid or gross purulence, a curvilinear incision should be made in the distal forearm to examine the flexor tendons and bursae. This is especially true for infections along the flexor pollicis longus (FPL) tendon sheath. An incision over the palmaris longus tendon in the forearm is versatile, but if there is only suspicion of FPL involvement, the incision can be made over the flexor carpi radialis (FCR) tendon. Ulnar retraction of FCR reveals the FPL tendon. Usual caution should be taken to avoid the palmar sensory branch of the median nerve, which branches from the median nerve about 6 cm proximal to the wrist crease and travels along the radial aspect of the FCR tendon. If more than one finger is involved, a larger midpalm incision should be made in a Bruner fashion. An additional irrigation tube may be placed proximally if the infection has tracked that far. Allow the fluid to drain via gravity at 20 mL/h. Do not try to rapidly force fluid into the sheath with an injection pump or syringe, because the fluid can leak into the subcutaneous space and can potentially create increased pressure in the finger. Slow continuous irrigation is less painful to the patient. Secure the drain to the skin of the palm with a single 3/0 nylon suture, taking care not to compress the tube. Tape the tube longitudinally to the arm to avoid it

A

B FIGURE 15.6 A A 21-month-old child with a human bite and flexor tenosynovitis. B A pediatric feeding tube was inserted in the flexor sheath. The bitten tissue over the volar PIP joint was sharply excised.

being inadvertently pulled out. Close the palmar wound loosely with skin sutures. A well-padded plaster or fiberglass dorsal splint is placed with the hand in the position of safety (wrist slightly extended, metacarpal joints flexed, and interphalangeal joints in neutral). The irrigation will make the dressing wet, and an absorbent pad wrapped around the arm is helpful in keeping the bed dry. The pad can be replaced as needed by the nursing staff. If the splint is dorsal and the hand is resting in an elevated position on a pillow or foam wedge, it will usually rest in a palm-down fashion, and the splint will get less wet and be more likely to stay intact. The dorsal position also allows the surgical team to look under the wraps at the wound without completely removing the dressing and potentially dislodging the irrigation tube. Depending on the severity of the infection and concomitant medical problems, the author’s preference is to keep the drain in place for 24–72 hours. Once the drain is removed, the therapist can educate the patient on active motion.

214 Hand and Upper Extremity Reconstruction Volar Bruner approach The entire sheath may be exposed via Bruner incisions (Fig. 15.7) if there are multiple areas of erosion through the skin along the flexor sheath; if there has been widespread damage to the volar skin; if there is concern of retained foreign material due to an injection injury; or if there is concern about a necrotizing process. The wound may be left open and closed in a delayed fashion, or loosely tacked closed at the time of the surgical drainage. Wet to damp coarse mesh gauze or feeding tube irrigation may be used.

Postoperative wound care Numerous methods of postoperative wound care have been described: catheter irrigation, finger soaks in sterile water, sterile saline, or tap water, wet to damp dressing changes with coarse mesh gauze, non-stick dressings with Vaselineimpregnated gauze, or silver-impregnated antimicrobial dressings. Skin cleansers such as Techni-Care may be useful acutely, but detergents, iodine, and peroxide may delay healing.30,31 One should consider the efficacy, ease, patient comfort, and cost associated with each of these treatments. There is no evidence to support any of these methods.9,28,32

A

B FIGURE 15.7 A Severe purulent flexor tenosynovitis tracking into the palm with destruction of the A1 and A2 pulleys. B The wound healed by secondary intention.

Felon/paronychia Anatomy

Paronychia is an infection of the tissues around the nail bed. The paronychium is the tissue folds lateral and medial to the nail; the eponychium is the fold proximal to the nail; the hyponychium is the tissue just distal and volar to the nail. The perionychium is the complex of the nail, nail bed, and paronychial folds.12 Paronychial infections can spread beneath the nail, or may spontaneously decompress around the nail fold. A felon is an infection isolated to the digital pulp. The anatomy is unique: the digital skin of the volar pad is attached to the periosteum by multiple septa encasing fat and sweat glands.12,25

Surgical drainage If the infection has not responded to a short course of warm soaks and oral antibiotics, surgical drainage should be performed. In many cases this can be done in a minor procedure room or office setting using a digital block and finger tourniquet. A thorough history should reveal the mechanism and suggest infective organisms that may be considered as etiologic agents. Purulent materials should be sent for culture. The method for draining a paronychia is chosen according to the extent and location of the abscess. If the skin over the abscess appears to be attenuated, one can make a longitudinal incision over the point of maximal swelling running parallel to the paronychial fold. If the edema and cellulitis are more diffuse, inserting a fine tissue scissor below the surface of the nail into the fold and spreading will drain the abscess. If there is evidence of subungual purulence, elevating and removing the lateral or medial 3– 4 mm of nail plate will allow drainage. If the infection involves the paronychium and eponychium and appears to be associated with a deeper proximal abscess, an incision should be made at each juncture of the paronychial and eponychial folds and extended proximally perpendicular to the fold. The eponychial fold is elevated, the wound irrigated, and a small wick left in place. Two sutures should be placed to realign the nail fold. Felons should be drained through a minimal longitudinally directed incision. If the infection is coming to a point, the incision should be made over the apex. If the area of involvement is symmetrical over the pulp, the incision can be made in one of several locations (Fig. 15.8). Avoid making an incision that traverses more than two sides of the fingertip (i.e., the fish-mouth incision). This incision creates a proximally based volar flap and frees the volar pad from the bone. It rarely heals well, and can be chronically deforming and uncomfortable.25 It is preferable to keep the incision off of the distal tip of the finger; lateral or medial incisions work well. A small curved tissue scissors should be placed just superficial to the periosteum and spread to allow drainage of all pockets of purulence across the volar pad of the finger. The wound should be copiously irrigated with saline. Obviously devitalized tissue should be excised. The wound should not be closed.

Techniques for Treating Finger Infections 215

FIGURE 15.8 Acceptable incisions for drainage of a felon along the volar pad and midaxial line of the finger.

FIGURE 15.9 X-ray showing septic arthritis caused by a cat bite.

Postoperative care A small Penrose drain or piece of gauze wick may be left in the wound for 1–2 days to allow it to drain. The fingertip can be soaked in saline or tap water for 10 minutes three times a day, or irrigated with a small syringe until the acute inflammation and drainage have subsided.

Septic arthritis

Anatomy of small joints The interphalangeal joints are uniaxial (hinge) joints supported on the palmar side by a thick volar plate and laterally and medially by the collateral and accessory collateral ligaments. The volar plate and collateral ligaments are attached, adding to the stability of the joint. The dorsal capsule is fairly thin and the joint is protected largely by the extensor tendon mechanism. Because of the relative thinness of the dorsal capsule, intra-articular infections spontaneously extend dorsally more frequently than in any other direction. Interphalangeal joints have a high level of congruency and are inherently stable. They have minimal rotatory motion, and movement is largely limited to flexion and extension.

Exposure A dorsal midline curvilinear incision is appropriate for access to the joint. When possible, it is preferable to avoid splitting the tendon because early movement is advisable after drainage of the joint. Cultures should be taken, copious irrigation performed, and the wound closed loosely (if at all). If the joint shows evidence of destruction, it is likely that an arthrodesis will be indicated for joint stability and minimization of pain. The arthrodesis should be delayed until the infection is cleared and the wounds healed.

Postoperative care A small drain or irrigation catheter may be left in the wound. The patient should be warned that stiffness, pain, and arthritis are not uncommon after joint infections13,21,24

FIGURE 15.10 A dorsal subcutaneous abscess which did not invade the interphalangeal joint or track volarly. After surgical debridement, it healed by secondary intention.

(Fig. 15.9). Taking the patient back to the operating room for a second or third look is reasonable if pain, swelling, or redness are not abating within 24–48 hours postoperatively.

Subcutaneous abscess Anatomy

Abscesses occasionally undermine the skin widely and cause overlying necrosis but do not invade into the tendon sheaths or joints (Fig. 15.10). This is more common over the dorsal aspect of the finger owing to the thinner skin, but it is possible for felons also to rupture through the volar pad if sufficiently neglected. This infection is often seen in people who have poor general health maintenance practices.

216 Hand and Upper Extremity Reconstruction Exposure

POSTOPERATIVE CARE

This infection can usually be managed in the minor procedure room under local anesthesia and a digital tourniquet. All grossly necrotic tissue must be sharply excised and the wound undermined with a hemostat or other small probe. Care should be taken to stop debriding when the tissue begins to ooze, as aggressive debridement may necessitate more extensive reconstruction.

Early involvement by a qualified hand therapist is beneficial for outcome.1,18,37 They are able to assist the patient perform protected movements, carry out treatments that hasten the resolution of inflammation, encourage psychological as well as physiological adaptation to the injury, and recognize patients who are not progressing as expected and for whom additional treatment may be indicated.

Postoperative care Care for this wound is as previously mentioned with soaks or irrigation, but because of the loss of skin, reconstruction with skin grafts or local flaps may be indicated once the infection has resolved. Antibiotics should be tailored to the infective organism, and the choice of antibiotic should reflect the possibility of poor compliance on the patient’s part. It may be desirable to see this patient several times a week to ensure compliance with care and ongoing healing.

CONCLUSION Finger infections can be associated with impressive inflammation. As is true in all wounds, rapid progression through the inflammatory phase into the building and remodeling

Clinical Pearls Organisms that may have pathognomonic characteristics:

Optimizing outcomes ● ● ● ● ●

● ● ●

Prompt surgical treatment Appropriate use of antibiotics Assurance that infection is completely drained Meticulous tissue handling technique Judicious debridement of tissue with removal of all foreign matter Irrigation or soaking Early motion Reduce inflammation through therapy

COMPLICATIONS AND SIDE EFFECTS OF FINGER INFECTIONS AND THEIR CARE All digital infections can be complicated by skin loss, stiffness, chronic edema, prolonged inflammation, osteomyelitis, and pain. Infections can be inadequately treated if the infective organism is drug resistant or unusual. Surgical intervention can be associated with inadvertent injury to nerves, arteries, and tendons, and failure to adequately debride necrotic tissue or remove all foreign material. Costs include hospitalization, surgery, time lost from employment and difficulty with activities of daily living. Later attempts to reconstruct tissues could be associated with recurrence of infections.33,34 Complications can be more specific to various infections: purulent tenosynovitis can cause tendon rupture; septic arthritis can progress to osteoarthritis or osteomyelitis. Acute bacterial finger infections may be confused with myriad other medical conditions, including gout, calcium pyrophosphate deposition disease, herpetic whitlow, spider bites, metastatic cancer, rheumatoid arthritis, and flares of other arthritides. Infections caused by mycobacteria may be indolent and persistent, resisting resolution with standard antibiotics and wound care.35,36

●

Staphylococcus spp. are pyogenic

●

Streptococcus spp., Sporothrix schenkii, and mycobacteria are associated with lymphangitis

●

Streptococcus may have a rapid course with systemic signs of illness

●

Sporothrix schenkii have violaceous ulcers along the lymphatic channels

●

Pseudomonas has a sweet and musty odor and may have a greenish color

●

Polymicrobial infections have a foul malodor and dark tan purulence

●

Clostridia have a sharp and pungent odor with tissue necrosis

●

Mycobacteria are associated with chronic course, are nonresponsive to antibiotics and require aggressive surgical treatment

●

Herpetic whitlow is characterized by small vesicles, possibly preceded by a prodrome and accompanied by disproportionate pain

Organisms may be more frequently seen in certain clinical settings ●

Pasteurella multocida is associated with animal bites

●

Eikenella corrodens is associated with human bites

●

Pseudomonas aeruginosa and Serratia spp. are associated with intravenous drug abuse, diabetes mellitus, and immunocompromised individuals

●

Sporothrix infections are associated with rose thorn punctures

●

Mycobacteria are associated with traumatic fresh or salt water exposures

●

Fungal infections are found in immunocompromised patients

Techniques for Treating Finger Infections 217 phases is ideal.38 Minimization of inflammation is ensured by early recognition of the problem, surgical drainage of abscess, surgical removal of foreign material, appropriate use of effective antibiotics, and collaboration with occupational therapists. Under the guidance of an occupational therapist, the patient can be provided with a home program for movement and edema control. If these points are attended to, and if the patient does not have comorbid conditions that compete with healing, the infection should rapidly abate and a reasonable outcome should be expected.

REFERENCES 1. Boles SD, Schmidt CC. Pyogenic flexor tenosynovitis. Hand Clin 1998; 14: 567–578. 2. Brook I. Management of human and animal bite wounds: an overview. Adv Skin Wound Care 2005; 18: 197–203. 3. Chang MC, Huang YL, Liu Y, Lo WH. Infectious complications associated with toothpick injuries of the hand. J Hand Surg [Am] 2003; 28: 327–331. 4. Marculescu CE, Berbari EF, Cockerill FR III, Somon DR. Unusual aerobic and anaerobic bacteria associated with prosthetic joint infections. Clin Orthop Relat Res 2006; 451: 55–63. 5. Rowe JG, Amadio PC, Edson RS. Sporotrichosis. Orthopedics 1989; 12: 981–985. 6. Karanas YL, Yim KK. Mycobacterium tuberculosis infection of the hand: a case report and review of the literature. Ann Plast Surg 1998; 40: 65–67. 7. Francel TJ, Marshall KA, Savage RC. Hand infections in the diabetic and the diabetic renal transplant recipient. Ann Plast Surg 1990; 24: 304–309. 8. Klein MB, Chang J. Management of hand and upper-extremity infections in heart transplant recipients. Plast Reconstruct Surg 2000; 106: 598–601. 9. Wysocki AB. Evaluating and managing open skin wounds: colonization versus infection. AACN Clinical Issues: Adv Pract Acute Crit Care 2002; 13: 382–397. 10. LeBlanc DM, Reece EM, Horton JB, Janis JE. Increasing incidence of methicillin-resistant Staphylococcus aureus in hand infections: a 3-year county hospital experience. Plast Reconstruct Surg 2007; 119: 935–940. 11. Kiran RV, McCampbell B, Angeles AP, et al. Increased prevalence of community-acquired methicillin-resistant Staphylococcus aureus in hand infections at an urban medical center. Plast Reconstruct Surg 2006; 118: 161–166. 12. Zook EG. Understanding the perionychium. J Hand Ther 2000; 13: 269–275. 13. Murray PM. Septic arthritis of the hand and wrist. Hand Clin 1998; 14: 579–587. 14. Small LN, Ross JJ. Suppurative tenosynovitis and septic bursitis. Infect Dis Clin North Am 2005; 19: 991–1005. 15. Gaar E. Occupational hand infections. Clin Occup Environ Med 2006; 5: 369–380.

16. Neviaser RJ. Tenosynovitis. Hand Clin 1989; 5: 525–531. 17. Schnall SB, Vu-Rose T, Holtom PD, et al. Tissue pressures in pyogenic flexor tenosynovitis of the finger. Compartment syndrome and its management. J Bone Joint Surg 1996; 78: 793–795. 18. Glass KD. Factors related to the resolution of treated hand infections. J Hand Surg [Am] 1982; 7: 388–394. 19. Harris PA, Nanchahal J. Closed continuous irrigation in the treatment of hand infections. J Hand Surg [Br] 1999; 24: 328–333. 20. Gosain AK, Markison RE. Catheter irrigation for treatment of pyogenic closed space infections of the hand. Br J Plast Surg 1991; 44: 270–273. 21. Boustred AM, Singer M, Hudson DA, Bolitho GE. Septic arthritis of the metacarpophalangeal and interphalangeal joints of the hand. Ann Plast Surg 1999; 42: 623–628. 22. Gutowski KA, Ochoa O, Adams WP Jr. Closed-catheter irrigation is as effective as open drainage for treatment of pyogenic flexor tenosynovitis. Ann Plast Surg 2002; 49: 350–354. 23. Schecter WP, Markison RE, Jeffrey RB, et al. Use of sonography in the early detection of suppurative flexor tenosynovitis. J Hand Surg [Am] 1989; 14: 307–310. 24. Shirtliff ME, Mader JT. Acute septic arthritis. Clin Microbiol Rev 2002; 15: 527–544. 25. Canales FL, Newmeyer WL 3rd, Kilgore ES Jr. The treatment of felons and paronychias. Hand Clin 1989; 5: 515–523. 26. Russell RC, Williamson DA, Sullivan JW, et al. Detection of foreign bodies in the hand. J Hand Surg [Am] 1991; 16: 2–11. 27. Peterson JJ, Bancroft LW, Kransdorf MJ. Wooden foreign bodies: imaging appearance. Am J Roentgenol 2002; 178: 557–562. 28. Campton-Johnston S, Wilson J. Infected wound management: advanced technologies, moisture-retentive dressings, and die-hard methods. Crit Care Nurs Q 2001; 24: 64–77. 29. Rosenbaum DH Jr, Degnan GG. Facilitating difficult catheter passage. Orthop Rev 1993; 22: 396–398. 30. Wilson JR, Mills JG, Prather, ID, Dimitrijevich SD. A toxicity of skin and wound cleansers used on in vitro fibroblasts and keratinocytes. Adv Skin Wound Care 2005; 18: 373–378. 31. Grubbs BC, Statz CL, Johnson EM, et al. Salvage therapy of open, infected surgical wounds: a retrospective review using Techni-Care. Surg Infect 2000; 1: 109–114. 32. Leaper DJ. Silver dressings: their role in wound management. Int Wound J 2006; 3: 282–294. 33. Ammon P, Stockley I. Allograft bone in two-stage revision of the hip for infection. Is it safe? J Bone Joint Surg 2004; 86: 962–965. 34. Hart JP, Eginton MT, Brown KR, et al. Operative strategies in aortic graft infections: is complete graft excision always necessary? Ann Vasc Surg 2005; 19: 154–160. 35. Regnard PJ, Barry P, Isselin J. Mycobacterial tenosynovitis of the flexor tendons of the hand. A report of five cases. J Hand Surg [Br] 1996; 21: 351–354. 36. Hess CL, Wolock BS, Murphy MS. Mycobacterium marinum infections of the upper extremity. Plast Reconstruct Surg 2005; 115: 55e–59e. 37. Mancini LH, Fort LK. Rehabilitation of the infected hand. Hand Clin 1989; 5: 635–641. 38. Menke NB, Ward KR, Witten TM, et al. Impaired wound healing. Clin Dermatol 2007; 25: 19–25.

CHAPTER

16

Dupuytren’s Contracture Warren C. Hammert

INTRODUCTION Our understanding of Dupuytren’s disease and the contracture process has evolved over the years. We have progressed from the early description of contracture release1 to our current understanding and many treatment modalities. Multiple treatment techniques have been described, ranging from simple division of the contracted fascia to attempted complete excision of the diseased tissue. The evolution of our understanding of Dupuytren’s disease and its early treatment dates back to the late 18th and early 19th centuries.2 The condition was ultimately named after Baron von Dupuytren, who described his technique for release of the contracture in the 1830s. In order to understand the process, one must have a clear understanding of the nomenclature and the biology behind the process.3 A nodule is the early palpable mass in the palm. In addition to the clinical description, it can also be used to describe a histologic pattern. The term band is used to describe normal fascia and the term cord describes the diseased fascia. The term diathesis is used to describe a more aggressive, severe form that begins earlier in life and often involves multiple sites (plantar aspect of the feet: Ledderhose’s disease; the penis: Peyronie’s disease; and the dorsal aspect of the PIP joints: Garrod’s knuckle pads) in addition to involvement of the palmar aspect of the hands.

HISTOLOGY The nodules do not occur randomly, but at points along the axis of the digital rays. They progress to a cord and the resultant contracture.4 The myofibroblast is the cell that has been implicated in the contracture process.5,6 This has been demonstrated in studies showing that Dupuytren’s fibroblasts consistently generate greater contractile forces than the controls, with those derived from the nodule having the greatest contraction.7–9 These cells contain myosin and actin, which induce the contraction. The myofibroblasts connect to each other via tight junctions and fibronectin. They are located in an extracellular matrix and

contain glycosaminoglycan as well as collagen types I and III.10,11 Multiple other tissue factors for this disease, including basic fibroblast growth factor,12,13 transforming growth factors β1 and 2,14–16 epidermal growth factor,16 plateletderived growth factor,17 nerve growth factor,18 and matrix metalloproteinases,19 have been implicated, but the exact mechanism that stimulates the myofibroblasts to begin the contractile process has not been elucidated.20 Three histologic phases have been described in the disease process: proliferative, involutional, and residual. The proliferative phase is characterized by an increased amount of immature fibroblasts and myofibroblasts, minimal extracellular matrix, and increased numbers of pericytes to create increased, disorganized cellularity. The involutional phase is characterized by a reduction in the number of fibroblasts and myofibroblasts, and increasing organization. The ratio of type III to type I collagen is increased, and the myofibroblasts align along the axis of the collagen bundles. In the residual phase the myofibroblasts essentially disappear, leaving densely packed bundles of collagen fibrils.

GENETICS/CAUSE Although the true etiology is unknown, most studies indicate a higher incidence in populations of northern Europe and persons of northern European ancestry.21 There appears to be an autosomal dominant pattern of inheritance with variable penetration. The prevalence increases with increasing age and the disease is more common in males.22 In addition, environmental influences may play a role, as it is more commonly seen in Indian patients living in England.23 In spite of attempts to determine the true cause of Dupuytren’s disease, its true etiology has eluded us. It has been linked to many different processes, but these processes do not afflict most patients. It is often seen in diabetics,24 but this form is somewhat different and more commonly affects the radial aspect of the hand. Alcohol has been reported to be associated, but the cause and effect

219

220 Hand and Upper Extremity Reconstruction relationship is not clear.25–27 The increased association with epilepsy is related to medications used to treat epilepsy, rather than to the disease itself.27,28 There is no evidence that treating any of these conditions will affect the Dupuytren’s process; the treatment should be directed towards the hand and not the systemic process.

ANATOMY AND PATHOLOGY A clear knowledge of the anatomy of the normal palmar fascia is essential to understanding the disease process and

its management. As the palmar fascia extends distally from the palm into the digits, it is divided into three anatomic layers. In the palm, the palmaris longus continues distally as the palmar fascia. These longitudinal fibers of the palmar fascia run superficial (volar) to the transverse fibers. At the distal end of the transverse fibers, the longitudinal fibers split into three layers (Fig. 16.1A–C). The first layer inserts into the skin between the distal palmar crease and the palmodigital crease, and is known as the pretendinous band. These fibers insert at a more proximal location along the ulnar aspect of the hand and move distally as they progress

Pretendinous bands (longitudinal)

Natatory ligament (distal commissural ligament)

Transverse fibers Neurovascular bundles

Natatory ligament (proximal commissural ligament)

Layer 1 Pretendinous band Layer 3 Deepest layer (passing around MP joints)

Layer 2 Spiral bands (deep to neurovascular bundles) Transverse fibers

Pretendinous band

A

B

FIGURE 16.1 A Diagram of anatomy of palmar fascia and pretendinous bands. B Diagram of palmar fascia as it separates into three layers at level of MP joint. C Diagram of layers of digital fascia.

Grayson’s ligament (superficial to neurovascular bundle)

Natatory ligament

Cleland’s ligament (deep to the neurovascular bundle) Lateral digital sheet

Neurovascular bundle

Spiral band

C

Pretendinous band

Transverse fibers of palmar fascia

Dupuytren’s Contracture 221 towards the radial side. The second layer dives deep to the neurovascular bundle and becomes continuous with the lateral digital sheet. This layer is known as the spiral band, and is responsible for displacement of the neurovascular bundle. The third layer continues deeper, passing around the flexor tendons along the side of the metacarpophalangeal (MP) joint.29,30 As the pretendinous bands become involved and contracture develops, they are termed pretendinous cords and cause contracture of the MP joints. As the deeper layers of fascia contract, they contribute to contracture of the proximal interphalangeal (PIP) joint. The central cord is a longitudinal continuation of the pretendinous cord and inserts along the base of the middle phalanx. The lateral cord is an extension from the natatory ligament to the lateral digital sheet. In the small finger, it attaches to the abductor digiti minimi and contributes to PIP joint contracture. The spiral cord develops from the second layer of fascia, as an extension of the pretendinous band. After wrapping around the neurovascular bundle, it joins the lateral digital sheet and causes contracture of the PIP joint through the attachment of Grayson’s ligaments to the flexor sheath and skin (Fig. 16.2A,B). Occasionally, distal extension will contribute to contraction of the DIP joint.30,31 Some individuals will have isolated digital involvement. In this scenario, the cord originates from the periosteum at the base of the proximal phalanx in conjunction with adjacent ligaments and intrinsic tendons. It can proceed in an oblique direction to displace and then cross the neurovascular bundles before inserting on the bone and/or flexor tendon sheath of the middle phalanx.32 In some cases it will continue distally, deep to the neurovascular bundle, and attach to the distal phalanx, causing DIP joint contractures, and is known as the retrovascular cord (Fig. 16.3A, B).30 The thumb is much less commonly involved than the ulnar aspect of the hand and has a different pattern of contracture, as the natatory ligament and the proximal commissural ligament are responsible. These are parallel structures that run transversely across the first web space, from the radial aspect of the thumb to the radial aspect of the index finger in the region of the MP joint and the metacarpal, rather than extending into the thumb (Fig. 16.1A). Thus, contracture results in an adduction contracture of the thumb, rather than flexion of the IP joint.30,33

Grayson’s ligament

Lateral digital sheet

Neurovascular bundle

Pretendinous band Spiral band

A

Grayson’s ligament

Lateral digital sheet Neurovascular bundle displaced toward midline by contracted spiral cord

Spiral cord

B FIGURE 16.2 A Diagram of fascial layers involved in spiral band. B Diagram of spiral band as it contracts and becomes spiral cord.

INDICATIONS AND CONTRAINDICATIONS Indications

Progression of disease ● ●

Functional disability Hygiene issues (inability to keep hand clean and skin healthy).

Goal of surgery ● ●

Release the contracture (or at least improve it) Dupuytren’s disease cannot be cured and the tissue can not be totally removed.

Contraindications Stable disease without functional impairment Medical conditions preventing safe surgical procedure ● Unable to participate in postoperative rehabilitation program. The mere presence of Dupuytren’s disease is not an indication for surgical intervention. The most important considerations are the degree of functional loss and the rate of progression. There are many patients who notice a ● ●


Cleland’s ligaments (deep to retrovascular cord)

Retrovascular cord

Central cord

A

FIGURE 16.4 Houston’s table top test – the patient places the hand flat on the table. Inability to place the hand flat on the table is secondary to contracture of the MP joint, PIP joint, or both and may be an indication for surgery.

B FIGURE 16.3 A Diagram of fascia and components of retrovascular cord. B Clinical photo of contracture involving PIP and DIP joints with retrovascular cord.

nodule in the palm, which may develop into a small cord, but which does not cause any functional disability. These patients can be followed using Houston’s tabletop test (Fig. 16.4). If the patient places his or her hand flat on the table and there is no separation between the palm or digit and the table, it is reasonable to teach the patient what to look for and see them again if contracture begins to develop. If the hand does not lie flat on the table, it can be placed with the ulnar side against the table and the digits actively extended. The hand is then traced on a piece of paper and the patient is taught how to check for progression of the contracture by periodically checking to see whether the hand lies within this outline. This will help objectively determine the rate of progression. In addition, measure-

ments of contracture and range of motion are measured at the affected joints. As a general rule, MP joint contractures can be corrected even when severe and long-standing. The PIP joint is much less forgiving and it is more difficult to maintain long-term correction. Taking into consideration the loss of function and progression of the contracture, the author will consider (but not always perform) surgery when there is an MP joint contracture of 30º or more and any degree of PIP joint contracture. The patient must have a clear understanding and realistic expectations. In general, they must be able to comply with the prescribed postoperative therapy program to have a good outcome. There are, however, some patients whose ability to comply with the therapy program is limited but who may still be candidates for surgery. These are patients with severe contractures whose hygiene and wounds are problematic. This situation may occur in a patient who has had a stroke, resulting in limited ability to comply with therapy, but whose contracture is severe, resulting in maceration of the tissue in the palm and inability to keep the hand clean. These patients are often candidates for more limited procedures, such as fasciotomy.

Dupuytren’s Contracture 223

PREOPERATIVE HISTORY AND CONSIDERATIONS Currently, the treatment of Dupuytren’s disease is still surgical. Oral non-steroidal anti-inflammatory medications have been suggested, but have not been found to be effective. Triamcinolone injections have been shown to slow the growth process, but not eliminate it. 34 Collagenase injections have shown promise and are in the third stage of clinical trials, but are currently not available for routine use.35 In those patients who for medical reasons are not good candidates for surgery, or who may not be able to complete the required therapy, fasciotomy can be performed as an office-based procedure and has been shown to be effective in the management of MP joint contractures.36 The procedure can be performed under local anesthesia. This cord can be sharply transected with an 11 blade or an 18-gauge needle, allowing the involved digit to be straightened. As this is a blind procedure, there is the possibility of injury to tendons or neurovascular structures, and recurrence is more likely. The patient must understand that there are risks involved with the procedure and that the goal is to release the contracture, not to remove or cure the disease. Injury to the digital nerves or vessels is rare, but can occur even with an experienced surgeon. Contractures, especially at the PIP joint, may not be completely released, and recurrence and extension of disease are common.37 Radiographs should be obtained to look for underlying osteoarthritis, as this makes postoperative stiffness more likely. This should be discussed with the patient before surgery. The procedure is generally completed on an outpatient basis under regional or general anesthesia. Prior to the surgery, a decision must be made about management of the skin, the contracted fascia, and the joints. Decisions regarding the skin include orientation of the incision and the method of closure, and whether a dermofasciectomy would be beneficial, as some feel the skin may be the source of recurrence.38 The skin can be incised in a zigzag fashion initially, or a straight longitudinal incision can be used, with conversion of the straight line to a zigzag orientation by z-plasties (Fig. 16.5). Options for closure include closing the entire incision or leaving a transverse portion open to heal secondarily.39,40 A dermofasciectomy can be used which involves simultaneous excision of the skin and contracted fascia and replacing the skin with full-thickness grafts. Multiple variations of these skin incisions and methods of closure have been proposed, and all can be used successfully. The decision regarding management of the fascia considers the amount to be excised: complete excision of all involved fascia (fasciectomy) versus removal of a portion (fasciotomy). Variations of complete removal have been proposed and include radical fasciectomy, which involves extensive removal of palmar fascia in the hope of reducing the chance of recurrence, and a more limited fasciectomy, which involves the removal of diseased fascia causing the contracture in the involved digit.

A B

C

FIGURE 16.5 Diagram of commonly used skin incisions for exposure of contracted fascia. A Multiple V-Y incisions. B Straight-line incision closed with multiple z-plasties. C Zigzag (Bruner) incisions.

Management of the MP joint is typically straightforward as removal of the fascia almost always allows complete extension of the joint. Management of the PIP joints is more difficult. Depending on the duration and severity of the contracture, removal of the involved fascia may not completely release the joint. It is generally accepted that if the joint is within 30º of full extension following fasciectomy, further efforts to release the contracture are not beneficial in the long term. If the residual contracture is greater than 30º, it is probably beneficial to address the PIP joint by releasing the check-rein ligaments of the volar plate, followed by the accessory collateral ligaments and the proper collateral ligaments, checking for PIP joint extension following each step and stopping when the contracture is less than 30º. If these maneuvers are not successful, further efforts are not going to be beneficial in the long term. Although it is not routinely performed, patients with severe PIP joint contractures may be candidates for PIP joint arthrodesis. This will allow shortening of the digit, which will reduce the tension on the neurovascular bundle when the digit is straightened, and allow the joint to maintain a functional position following osseous healing.

224 Hand and Upper Extremity Reconstruction In rare situations, amputation should be considered. This would most likely involve a patient who has a problem with hygiene who is unable to cooperate with the required therapy.

OPERATIVE APPROACH Pearls and technical points Understand the normal and diseased (contracted) palmar fascia ● Pretendinous cord ● Spiral cord ● Central cord ● Retrovascular cord MP joint contracture Exposure of cord ● Preservation of transverse fibers of palmar fascia ● Excise cord from proximal to distal with direct visualization of the neurovascular bundle ●

PIP joint contracture Exposure of cord to distal extent ● Identify neurovascular bundles proximally ● Excise cord with direct visualization of neurovascular bundles ● Fixed joint contracture following fasciectomy ● Less than 30º – accept ● Greater than 30º – joint release ● Volar plate – check-rein ligaments ● Accessory collateral ligaments ● Proper collateral ligaments ●

The procedure is performed under either regional or general anesthesia. The author prefers regional, as this will typically allow the patient to return home with the block still in effect, making him/her more comfortable. A pneumatic tourniquet is placed on the upper arm. Prior to inflation, the skin incisions are outlined with a marking pen. A variety of incisions can be used effectively, but the author generally prefers a zigzag type of incision, modified, if necessary, by creating a transverse limb in the distal palmar crease and the palmodigital crease (Fig. 16.6A). An Eschmarch wrap is used to exsanguinate the upper extremity and the tourniquet is inflated to 100 mmHg above the preoperative systolic pressure. I begin the operation by incising and elevating the palmar flaps to expose the entire area of the diseased, contracted fascia, from the proximal palm to the palmodigital crease (Fig. 16.6B). The skin flaps should be elevated at the level of the palmar fascia, keeping all the subcutaneous fat on the flap, exposing the longitudinal contracted palmar cords (pretendinous cords) and the non-contracted transverse bands. The digital neurovascular bundles will lie deep to the transverse fascia and are protected at this level. The transverse fascia is not diseased and does not need to be completely removed. The longitudinal pretendinous cord is divided proximally and elevated to the distal aspect of the transverse fascia, which will coincide with the distal palmar crease. The neurovascular

bundles can be identified along each side of the pretendinous cord as they emerge from the distal aspect of the transverse fascia. After identification of the neurovascular bundle, the diseased pretendinous cord is transected distally (Fig. 16.6C), which should allow full extension of the MP joint. Management of the fascia causing contracture of the PIP joint requires a thorough understanding of the anatomy, as the neurovascular bundle is often displaced both centrally and superficially. With the neurovascular bundles visualized, the skin incision is carried distally to the level of the PIP joint. This can be designed as a zigzag Bruner-type incision or a straight-line incision, which is subsequently broken with z-plasties. These flaps are elevated at the level of the fascia, with all the subcutaneous tissue on the skin flap. Following flap elevation, the neurovascular bundles are protected and kept under direct visualization while the diseased fascia is excised. This will require excision of the spiral cord, which wraps around the neurovascular bundle, attaching to the lateral digital sheath, and Grayson’s ligament. Occasionally, a central cord will be present and extends from the region of the pretendinous cord to the region of the PIP joint. When both of these cords are present, the neurovascular bundle will be sandwiched between them. Occasionally, spiral bands will be present on both sides of the digit, pulling both neurovascular bundles together in the midline. Once the contracted fascia is exposed to its distal extent, and the neurovascular bundle has been identified and protected, the fascia is divided. Effort is made not to disrupt the flexor sheath (Figs 16.7 and 8). The PIP joint itself is now evaluated. Sometimes, it can be fully extended with gentle pressure. Occasionally, a cracking sound will be heard, which is the result of rupture of the vincula. There is considerable debate about the management of the PIP joint following excision of the contracted fascia. If the joint cannot be extended, a goniometer is used to measure the remaining contracture. If this is less than 30º I do not attempt further release, as the subsequent edema slows the recovery process and long-term maintenance of the final extension is usually not accomplished (Fig. 16.9). If the contracture is more than 30º I feel it is worth attempting further joint release. The flexor sheath is opened and the check-rein ligaments (proximal extensions of the volar plate at the PIP joint) are released along the radial and ulnar aspects. The joint is gently extended and again measured. If the contracture is still greater than 30º, the accessory collateral ligaments are released from their attachment to the volar plate, the joint is gently extended, and the remaining contracture is again measured. If still greater than 30º the proper collateral ligaments are released, which will allow full extension of the PIP joint.41 In patients with severe PIP joint contractures, long-term maintenance is unlikely even with PIP joint capsulotomy.42 The tourniquet is deflated and pressure is held during the reperfusion phase until the hyperemia has resolved. The perfusion of the digits and skin flaps is evaluated and hemostasis obtained with bipolar electrocautery. Digital perfusion may be delayed secondary to vasospasm from manipulation of the digital arteries, but should return if the


B

A

FIGURE 16.6 Clinical case involving MP joint contracture of the ring finger. A Zigzag skin incision outlined along the palmar cord. B Exposure of palmar cord. C Appearance of wound following removal of cord.

arteries have not been damaged. On rare occasions the digital vessels are intact, but there is inadequate perfusion secondary to stretching of the digital vessels. In this case, the digit is flexed to alleviate the tension on the vessel and circulation will be restored. If circulation is not restored, the digital artery must be reconstructed,43 and this may require vein grafts. The skin flaps are again evaluated. If there are large areas of buttonholing or areas of devascularization, these should be resected and replaced by skin grafts. If there is a

C

shortage of skin due to the prolonged flexed position, the skin can be advanced distally, leaving the palm open in the region of the distal palmar crease: the open palm technique, often incorrectly referred to as the McCash technique. (The open palm technique involves leaving a transverse portion of the palmar incision open and allowing it to heal secondarily.) The McCash operation, as originally described, involved extensive undermining of the skin, tunneling from the palmar incisions to the digital incisions, and advancement of the skin distally to close the finger wounds, while

226 Hand and Upper Extremity Reconstruction leaving the palm open. The skin incisions are closed and covered with a non-adherent dressing. I prefer a bulky soft dressing without a plaster splint, as the patients seem more comfortable, but a plaster splint is also acceptable.

Alternative technique: dermofasciectomy

A

In cases of recurrent disease, or where the skin is adherent to the underlying contracted fascia, which is presumably infiltrated by myofibroblasts, the skin and involved fascia can be removed as a composite resection. This will allow correction of the skin shortage and produce ‘firebreaks.’ (When the skin is excised and replaced with a skin graft, as in dermofasciectomy, large skin grafts can be used to replace skin shortage and the skin graft replaces the native skin (which is potentially infiltrated with myofibroblasts), creating an area of normal skin (skin graft) between two areas of potentially diseased skin (native skin infiltrated with myofibroblasts), which is referred to as a ‘firebreak’.) Although this does not eliminate the possibility of recurrence, there are reports of lower rates of recurrence.44–46 The procedure still involves identification and protection of the neurovascular bundles and excision of the diseased fascia, followed by joint release if necessary. The tourniquet is deflated and hemostasis obtained. The size of the defects is measured with the digits in full extension and full-thickness grafts are harvested, typically from the upper inner arm. The grafts are sutured in place and a bolster dressing is applied, followed by a plaster splint with the MP joints in slight flexion (30º) and the IP joints extended. I prefer to leave the dressing/splint in place for 7–10 days and delay therapy until the graft has taken.

B

Recurrence

C FIGURE 16.7 Clinical case involving isolated PIP joint contracture. A Prior to excision. B and C Following excision through transverse incisions.

Unfortunately, recurrence of disease is common. In patients who have had previous surgery for Dupuytren’s disease, the surgeon should attempt to discern between true recurrence (Dupuytren’s disease in the same area) or extension of disease (nodules and cords that develop in other unoperated areas).47 This sounds straightforward, but is often difficult to determine. The important point is whether there has been a previous dissection, as the anatomy will not be predictable, making the operation more difficult and timeconsuming. In addition, recurrence and altered sensation are common when operating on patients with recurrent Dupuytren’s disease.48 There is no way to predict which patients will develop recurrence, and no evidence linking recurrence to inadequate excision at the initial operation. Management of the skin and PIP joint is the critical factor in recurrent disease. With significant skin involvement, dermofasciectomy is often preferred. When operating in a previously dissected region of the palm or digit it can be very difficult to clearly identify the neurovascular bundles, and it is often advantageous to identify them proximally in unoperated tissue and follow them distally. Management of the PIP joint can be difficult, and if the contracture is severe, arthrodesis can be effectively used to prevent recurrent, problematic PIP joint


A

B

C

contracture. The remainder of the procedure is the same as for primary disease.

OPTIMIZING OUTCOMES As with many operations, a complete understanding of the normal and pathologic anatomy is essential. Patients must have realistic expectations and understand that the procedure is designed to relieve, or at least improve, the contracture, but not to remove all the Dupuytren’s tissue. They

FIGURE 16.8 Clinical case involving PIP and DIP joint contractures. A Appearance prior to incision. B Exposure of cord (note retrovascular cord associated with ulnar neurovascular bundle). C Appearance of incision immediately following closure (note the initial pale appearance of digit and skin flaps, which resolved with warm irrigation).

must be able to comply with the postoperative therapy program and understand that prolonged night-time splinting is often necessary to maintain optimal surgical results. If these conditions are met, the chances are that the patient will have a good result.

PITFALLS TO AVOID ●

Nerve injury: neurovascular bundles will be displaced toward the midline in the finger


E

●

●

●

D

FIGURE 16.8, cont’d D Appearance following healing. E Flexion following therapy.

Arterial injury: critical ischemia may develop, requiring microsurgical reconstruction Devascularization of skin flaps: resect and replace with full-thickness skin grafts Hematoma: meticulous hemostasis prior to wound closure

able to delineate clearly between tendon and contracted fascia. Injury to neurovascular structures typically occurs in the digit and is due to displacement of the neurovascular bundle by the spiral cord. When displaced, the digital vessel or nerve may appear as contracted fascia and be inadvertently transected. This can occur when the surgeon mistakenly identifies a strand of fascia as a digital nerve and transects the true nerve, or when a dorsal branch of the digital nerve is mistakenly identified as the proper digital nerve and protected while the true nerve is transected. If the transected nerve is identified, this should be repaired primarily or with a graft. If a digital vessel is found to be transected repair should be attempted, as recurrence of the contracture may require a repeat operation and injury to the other vessel would compromise digital survival. Often, diseased fascia is adherent to the skin and elevation of skin flaps results in a buttonhole. This may compromise the circulation and result in delayed wound healing. Occasionally there may be inadequate perfusion to the digit

COMPLICATIONS Unfortunately, the complication rate following surgery for Dupuytren’s contracture can be high and has been reported to be as high as 17%.49 Complications can result from intraoperative damage to structures or from early postoperative events. Late postoperative events, such as recurrence of contracture or extension of disease, should be considered adverse outcomes not complications. Intraoperative complications include injury to tendons and neurovascular structures, and devascularization of skin flaps. Tendon injury should not occur, as one should be


A

C

B

D

FIGURE 16.9 Clinical case involving middle and ring MP joints and significant ring finger PIP joint contracture. A and B preoperative photos. C Intraoperative photo prior to removal of cord. D Residual PIP joint contracture. This was less than 30º, so a decision was made not to proceed with joint release.

secondary to vasospasm from stretching of the digital vessels, as the vessels become shortened with prolonged flexion. If this does not resolve, the digit should be flexed to a point that allows for reperfusion. Early postoperative events are typically related to wound healing, for example hematoma formation, skin flap necrosis, or infection. Great care should be taken to prevent

hematoma formation, and the judicious use of Penrose drains will often prevent fluid from accumulating under skin flaps. When a hematoma is noted, the patient should be taken back to the operating room for evacuation and evaluation of the wound. The hematoma creates a dead space and stimulates mediators of inflammation, resulting in fibrosis and increased scarring. In addition, the

230 Hand and Upper Extremity Reconstruction hematoma is a nidus for infection. Skin necrosis typically occurs from the initial procedure (buttonholing, or the creation of flaps that are too thin) or from adequate flaps that become ischemic secondary to pressure from a fluid collection. If there is a large amount of skin necrosis, this should be debrided and consideration given to skin grafting the defect. Late postoperative events involving significant pain, swelling, stiffness, or vasomotor changes should be treated aggressively to reduce the chance of developing a chronic regional pain syndrome.

POSTOPERATIVE CARE A good postoperative program is essential to success.50 There is no consensus as to whether the use of a postoperative plaster splint is necessary. In addition, the optimal position for postoperative splinting has been debated, with no clear consensus. Some advocate the position of function with the MP joint flexed and the IP joints extended, whereas others advocate extending both the MP and the PIP joints. In cases without skin grafts (which are the majority) the author places the patient in a bulky soft dressing and has them see the therapist on the second or third postoperative day. They receive instructions in wound care, edema control, and active range of motion exercises. They also are fitted with a custom Orthoplast resting splint with both the MP and PIP joints in extension. This is removed for hygiene purposes and exercises. Cases managed with an open palm technique typically heal remarkably well, often with a scar that is difficult to discern. The patient is instructed on local wound care, coverage with a non-adherent dressing, and the importance of digital motion during the healing process. The healing time is variable, depending on the patient and the size of the wound, but is often complete in several weeks. In cases with a skin graft, I prefer to place a bolster over the graft and use a postoperative splint with the MP joints slightly flexed (approximately 30º) and the PIP joints in full extension. The splint is left undisturbed for 7–10 days and then removed for evaluation of the graft. If the graft is adherent, it is covered with a non-adherent dressing, an Orthoplast splint is made, and gentle active range of motion exercises are begun to restore flexion. If the graft has not taken, the cause must be determined (hematoma or fluid collection under the graft, inadequate immobilization, infection, etc.) and a decision must be made as to whether it is best to return to the operating room for repeat grafting or allow the wound to heal secondarily. The most important aspect of the postoperative course is to regain full flexion. This must be achieved even if it means allowing some residual flexion contracture to occur, as the patient will function much better with full flexion and limited extension than with full extension and limited flexion. In cases with residual PIP contracture and full flexion, dynamic splinting may help improve the contracture and, at the least, prevent it from becoming worse. Static night-time splinting is beneficial, as PIP joint con-

tractures are apt to recur. There is no optimal duration of splinting and this is patient dependent, but the author typically recommends a minimum of several months.

CONCLUSION Most of the current research on Dupuytren’s disease has been in the basic science arena, with efforts to improve our understanding of the disease process. The basic surgical tenets have not changed much over the years. Current advances in non-surgical treatment, such as the use of collagenase, will probably make current treatments obsolete, making an office-based injection for rupture of the cord the standard of care. In addition, further research into the basic science of the pathogenesis may some day allow us to determine susceptible individuals and thus stop the process before it begins. Until then, we must continue to treat this problem with the time-honored method of surgical fasciectomy. The variability of the disease due to the duration and severity of contracture has precluded researchers from analyzing outcomes as has been done for other upper extremity disorders, such as carpal tunnel syndrome and distal radius fractures. In spite of a paucity of objective data, the subjective improvement in function makes this a worthwhile procedure.

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31. McFarlane R. The finger. In: Dupuytren’s disease: biology and treatment. McFarlane R, McGrouther D, Flint M, eds. Edinburgh: Churchill Livingstone,1990; 155–171. 32. Strickland J, Bassett R. The isolated digital cord in Dupuytren’s contracture: Anatomy and clinical significance. J Hand Surg 1985; 10A: 118–124. 33. Hall-Findlay EJ. The radial side of the hand. In: Dupuytren’s disease: biology and treatment. McFarlane R, McGrouther D, Flint M, eds. Edinburgh: Churchill Livingstone, 1990; 168–175. 34. Ketchum L, Donahue T. The injection of nodules of Dupuytren’s disease with triamcinolone acetonide. J Hand Surg 2000; 25A: 1157–1162. 35. Badalamente M, Hurst L, Hentz V. Collagen as a clinical target: nonoperative treatment of Dupuytren’s disease. J Hand Surg 2002; 27A: 788–798. 36. Rowley DI, Counch M, Chesney RB, Norris SH. Assessment of percutaneous fasciotomy in the management of Dupuytren’s contracture. J Hand Surg 1984; 9B: 163–164. 37. Boyer M, Gelberman R. Complications of operative treatment of Dupuytren’s disease. Hand Clin 1999; 7: 161–166. 38. McCann BG, Logan A, Belcher H, et al. The presence of myofibroblasts in the dermis of patients with Dupuytren’s contracture: A possible source for recurrence. J Hand Surg 1993; 18B: 656–661. 39. McCash C. The open palm technique in Dupuytren’s contracture. Br J Plast Surg 1964; 17: 271–280. 40. Lubahn J. Open-palm technique and soft tissue coverage in Dupuytren’s disease. Hand Clin 1999; 7: 127–136. 41. Crowley B, Tonkin M. The proximal interphalangeal joint in Dupuytren’s disease. Hand Clin 1999; 7: 137–147. 42. Weinzweig N, Clulver J, Fleegler E. Severe contractures of the proximal interphalangeal joint in Dupuytren’s disease: Combined fasciectomy with capsuloligamentous release versus fasciectomy alone. Plast Reconstruct Surg 1996; 97: 560–566. 43. Jones NF, Hunag JI. Emergency microsurgical revascularization for critical ischemia during surgery for Dupuytren’s contracture: A case report. J Hand Surg 2001; 26A: 1125–1128. 44. Brotherston T, Balakrishnan C, Milner RH, Brown HG. Long-term follow up of dermofasciectomy for Dupuytren’s contracture. Br J Plast Surg 1994; 47: 440–443. 45. Hall PN, Fitzgerald A, Sterne GD, Logan AM. Skin replacement in Dupuytren’s disease. J Hand Surg 1997; 22B: 193–197. 46. Ketchum L, Hixson F. Dermofasciectomy and full-thickness grafts in the treatment of Dupuytren’s contracture. J Hand Surg 1987; 12: 659–663. 47. Gordon S. Dupuytren’s contracture: Recurrence and extension following surgical treatment. Br J Plast Surg 1956; 9: 286–288. 48. Roush T, Stern PJ. Results following surgery for recurrent Dupuytren’s disease. J Hand Surg 2000; 25A: 291–296. 49. Prosser R, Conolly W. Complications following surgical treatment for Dupuytren’s contracture. J Hand Ther 1996; 9: 344–348. 50. Mullins PA. Postsurgical rehabilitation of Dupuytren’s disease. Hand Clin 1999; 15: 167–174.

CHAPTER

Nerve Reconstructive Techniques in the Hand

17

Thomas H. Tung

INTRODUCTION Nerve injuries in the upper extremity can cause permanent impairment and have devastating consequences. Direct primary repair should be performed if possible. Large nerve gaps, proximal injuries and avulsion-type injuries prohibit direct repair and mandate secondary nerve reconstruction after the patient has recovered from the acute injury. Time constraints due to muscle atrophy after denervation and degeneration of the neuromuscular junction adversely influence the outcome. Until the last century, the results of nerve repair in the extremity, and especially of the brachial plexus, were viewed with pessimism. In the latter half of the 20th century, advances in peripheral nerve surgery, including improvements in nerve repair and grafting techniques, knowledge of the internal topography, injury pattern and regenerative ability of the peripheral nerve, have contributed to the improvement of outcomes. Advances in nerve repair and improved understanding of the internal topography of the nerve have contributed to the development of nerve transfers. Nerve to nerve transfers offer a superior alternative for functional restoration in isolated or multiple nerve injuries when early reinnervation of the target organ is necessary, such as in proximal injuries or delayed treatment. Expendable sensory or motor axons close to the organ allow for earlier regeneration and preclude the need for nerve grafts. This chapter describes the assessment of and criteria for nerve transfers, as well as the management and surgical techniques for well-established nerve transfer procedures.

NERVE REPAIR Indications ●

●

Transection of motor nerve; tension-free repair is possible to restore motor function. Transection of sensory nerve; tension-free repair is possible to restore critical sensation or to prevent neuroma formation.

Contraindications ●

Nerve injury in which primary repair will place excessive tension on the repair, or where postural positioning is required to minimize tension (for example bending the elbow to repair the lacerated ulnar nerve).

Preoperative and operative considerations After transection of a peripheral nerve, the nerve segment distal to the injury will undergo wallerian degeneration and the proximal nerve will undergo traumatic degeneration for a variable distance. Crush and avulsion injuries will produce a greater longitudinal zone of injury and degeneration than a sharp transection. Regeneration will then occur from the proximal nerve by the formation of regenerating units as each single axon ‘sprouts’ multiple axons that represent the minimum functional unit for regeneration (Fig. 17.1). The goal of a good nerve repair is to contain and permit the growth of these regenerating units into the remaining endoneurial tubes of the degenerated distal nerve, with minimal loss of sprouting axons at the repair site. Regenerating axons that are lost in the extraepineurial environment will contribute to a painful neuroma and may compromise target organ reinnervation. Optimal target organ reinnervation requires that motor, sensory, and autonomic axonal pathways be restored such that distal organs are reinnervated by axons of the appropriate modality.

Operative technique Nerve repairs may be performed using either an epineurial or a fascicular suturing technique (Fig. 17.2). The superiority of one method over the other has never been conclusively demonstrated, either clinically or experimentally, and therefore there is no general consensus as to which is better. Intuitively, there would seem to be greater potential for the proper alignment of axonal pathways of the appropriate modality with the fascicular repair, but for several reasons this is not realized clinically. Because the proper identifica-

233

234 Hand and Upper Extremity Reconstruction Growth cones with filopodia Basal lamina

Schwann cells

FIGURE 17.1 After transection of a single axon, multiple axons will ‘sprout’ from the proximal nerve stump forming a regenerating unit, whereas wallerian degeneration will occur distal to the injury.

in comparable or better overall fascicular alignment, resulting ultimately in an equivalent functional outcome. It is probably best to use aspects of both fascicular and epineurial repair techniques, depending on the nature and location of the injury and the fascicular arrangement of the injured nerve. With an acute, clean transection and with the aid of appropriate magnification, anatomic vascular markings on the epineurium can be relatively easily aligned, and an epineurial repair should suffice. If there is a proximal injury, the nerve is more likely to have a mono- or oligofascicular pattern at that level where an epineurial repair is again appropriate. Further distally, however, there will be a polyfascicular arrangement with a grouped fascicular pattern. Because of variations in the size of the groups and the diameter of the individual fascicles, it is often possible to match the proximal and distal ends with enough certainty to proceed with a grouped fascicular repair. Alternatively, a fascicular group can be repaired if its function is clear, and the remainder of the nerve can be repaired with epineurial sutures. A minimum number of fine microsutures should be used, avoiding neural tissue itself. The nerve repair must be tension free and adjacent joints should be moved to note any tension at the repair site. Any flexion or extension of the extremity or digit to facilitate a direct repair should be avoided.

A

B FIGURE 17.2 A Standard epineurial suture technique. B Group fascicular suture technique.

tion of fascicular function is difficult practically, it is possible that the direct suturing of groups of fascicles unintentionally results in improper alignment and modality mismatching, which then guarantees loss of functional recovery. There may also be more intraneural scarring because of the greater manipulation and suturing required for a fascicular repair. Although the epineurial repair technique is not as precise with regard to fascicular alignment, it may better allow neurotropic factors to influence the direction of regeneration of individual fascicles and result

Postoperative care Primary repairs should be immobilized for approximately 1–2 weeks, depending on the laxity at the repair site(s) and their ability to accommodate the full range of joint motion. Motion should then be encouraged to minimize scarring and adhesions around the nerve.

NERVE GRAFTING Indications ●

For the reconstruction of any critical motor or sensory nerve in which primary repair without excessive tension is not possible.

Nerve Reconstructive Techniques in the Hand 235 ●

●

Reconstruction of proximal injury to prevent neuroma formation but in which motor restoration may not be realistic. Nerve transfer for which a direct repair between the donor and recipient nerve is not possible


Primary nerve repair should be performed whenever possible to maximize axonal input to target organs.

Preoperative and operative considerations The use of nerve grafts is necessary when a tension-free primary repair is not possible. The critical length of a nerve gap for which a nerve graft is required will vary depending on the injured nerve and its anatomical location. For example, a nerve in the forearm can be mobilized both proximally and distally for a considerably greater distance than a digital nerve to overcome a small nerve gap. In particular, anterior transposition of the ulnar nerve can provide enough mobility to overcome a gap of several centimeters to permit an acceptable primary repair. Millesi has made the distinction between a nerve defect and a nerve gap. A nerve defect is the actual amount of nerve tissue that is lost, whereas a nerve gap is the distance between the proximal and distal ends of an injured nerve irrespective of whether nerve tissue is missing or not. If there is no actual loss of nerve tissue (nerve defect), the nerve gap results from scarring and contracture of the proximal and distal nerve stumps. If nerve tissue is lost, the nerve gap results from the combination of the nerve defect and contracture. A nerve gap will always be equal to or greater than the nerve defect, depending on the amount of contracture or displacement of the proximal and distal nerve segments. The presence of a nerve defect will complicate attempts to properly align injured fascicles, and it may be impossible to do so with large nerve defects because the topographical anatomy will vary considerably between the proximal and distal stumps. The association of long nerve grafts with a less optimal outcome may also be due to a more severe and higher level of injury, both of which may lead to more extensive neuronal cell death.

Operative technique Many of the principles of primary nerve repair are applicable to nerve grafting as well. The proximal and distal nerve ends must be prepared with the excision of all neuroma and scar tissue, and both the proximal and distal suture sites of the graft must be tension-free throughout the full range of motion of the injured region. It also remains essential that every attempt be made to align fascicles of the appropriate modality at the proximal and distal ends of the graft. Frequently it is not possible to distinguish between motor and sensory fascicles because at the proximal stump of a high injury the fascicles may be mixed. At the distal end, however, fascicular function can usually be identified and the distal end of the nerve graft can be sutured selectively to the

desired fascicle(s), usually motor. The non-critical sensory fascicles are excluded to optimize the restoration of critical motor function. The most commonly used donor nerves for grafting are the sural and the medial antebrachial cutaneous (MABC) nerves. The sural nerve is preferable in most cases because of minimal donor morbidity and the long length of nerve graft available. A single longitudinal incision on the posterior lower leg and calf will allow identification of all sural communicating branches and sufficient access for harvesting additional nerve graft material. Smaller step incisions may also be used, with or without the aid of a specialized sural nerve harvester or tendon stripper, but care must be taken and additional incisions may be needed to avoid damage to the donor nerve when managing the communicating branches. Up to 30–40 cm of graft length can usually be obtained. The MABC is also commonly used, especially in brachial plexus reconstructions, because it is often nonfunctional and therefore has no donor morbidity. The donor scar lies in the brachial sulcus of the medial arm, which is often required for the exposure and reconstruction of the injured nerves. Use of only the anterior branch will further minimize donor site morbidity if the nerve is functional. Up to 20 cm of nerve graft material of substantial size can typically be harvested. Other potential nerve grafts, depending on the size and length required, include the lateral antebrachial cutaneous (LABC) nerve and the radial sensory nerve for proximal radial nerve injuries because the sensory nerve will usually be dissected and excluded from the distal repair to optimize the recovery of motor function. Nerve laceration injuries can often be repaired primarily if managed acutely. Most delayed or secondary reconstructions will require nerve graft reconstruction because of nerve contracture as well as the need to trim scar tissue from the nerve stumps, which may inhibit regeneration. If there is a significant component of crush or avulsion injury, then nerve repair should be delayed for about 3 weeks, at which time the zone of injury will be more clearly discernible at the time of surgery to allow for adequate resection of all injured areas. If reoperation is deemed too risky or undesirable because of a need for vascular reconstruction, anticipation of intense scarring at the operative field, or poor patient condition, a generous resection of the injured nerve should be performed at the initial surgery and immediate nerve grafting performed to avoid secondary nerve grafting in an unfavorable condition. We advocate nerve graft repair of any nerve injury in which primary repair is not possible. Most injuries after 1 or 2 weeks will develop so much scarring and contracture of the nerve ends that primary repair will result in excessive tension at the repair site or may not even be possible. Delayed reconstructions will require resection of neuroma and scar tissue from both the proximal and distal nerve stumps, which will result in even larger nerve gaps. Lacerations of the median and ulnar nerves at the wrist or forearm should be reconstructed in a cabled fashion because of their larger size, and usually the sural nerve or the MABC is used as the graft. The median and ulnar nerves will usually require up to three to five cables, depending on the size of


FIGURE 17.3 Standard cable nerve graft technique for reconstruction of large-caliber nerves, with care taken to align fascicular groups as anatomically as possible.

the grafts, for the optimal size match (Fig. 17.3). An attempt should always be made to align the fascicular groups as anatomically as possible to provide appropriate motor or sensory innervation of distal targets (Fig. 17.4). High nerve injuries at the elbow or further proximally should be reconstructed early to permit reinnervation of critical motor targets. If reconstruction is being performed secondarily, we advocate graft reconstruction to manage pain due to neuroma formation, but we will perform nerve transfers to reinnervate critical muscles if the timing and distance will not permit successful muscle recovery prior to degeneration and fibrosis of motor endplates. If there is no pain or neuroma formation at the injury site, we do not reconstruct the nerve gap but rely on nerve transfers for motor and sensory reconstruction. Nerve gaps of the common or proper digital nerves will usually require a smaller graft such as the lateral antebrachial cutaneous nerve (LABC) from the proximal or mid forearm. The length of nerve graft used to reconstruct a gap should provide for tension-free nerve coaptation to permit early full range of motion and minimize the need for postoperative immobilization. Splinting may be desirable initially to minimize swelling and for the patient’s comfort, but otherwise is often not necessary.

A

B FIGURE 17.4 A Median nerve injury in the distal forearm resulting in a 5.5 cm nerve gap following neuroma excision. B Reconstruction with sural nerve graft using five cables.

Postoperative care

Preoperative and operative considerations

Nerve graft reconstructions should be immobilized for approximately 1 week, because there should be no tension at the repair site and the graft should be made long enough to easily accommodate the full range of joint motion. Motion should then be encouraged to minimize scarring and adhesions around the nerve.

Because of the donor site morbidity associated with nerve graft harvest, the use of readily available nerve conduits continues to be investigated experimentally and is being used clinically by some with success. A number of different biodegradable conduits of varying materials and sizes are currently available for clinical use, including nerve wraps that allow the surgeon to tailor the conduit diameter to meet his or her particular needs. Non-degradable nerve tubes are not preferred because of the potential for foreign body reaction and additional scarring. It has been shown experimentally that inserting a small segment of nerve tissue in the middle of the conduit, or pieces of morcellized nerve within the conduit, will improve regeneration and may even allow regeneration across a somewhat longer nerve gap. The current recommendations for their use include the reconstruction of nerve gaps of no more than 3 cm in small-diameter sensory nerves. A conduit should be used for a gap of no more than 5 mm if reconstructing a larger-diameter nerve.

NERVE CONDUITS Indications ●

Reconstruction of a sensory nerve gap of no more than 3 cm.


Reconstruction of a motor nerve gap remains controversial and the use of a nerve graft is considered by most to be more appropriate.

Nerve Reconstructive Techniques in the Hand 237

FIGURE 17.5 Suture technique for nerve gap reconstruction using nerve conduit. Proximal and distal nerve ends are invaginated into the tube for 2–3 mm.

FIGURE 17.6 Nerve conduits used to reconstruct the radial sensory and lateral antebrachial cutaneous nerve (LABC) gaps following injury and neuroma formation.

Operative technique

Principles of nerve transfer

The technique involves inserting the nerve stump into the conduit for approximately 2–3 mm and securing it with nylon microsutures, which can be performed in a horizontal mattress fashion to help guide the nerve stump into the tube (Figs 17.5, 17.6).

Many of the considerations for tendon transfer also apply to nerve transfer. The selected donor nerve(s) must be redundant and/or expendable. It is preferable that the donor nerve branch innervates a muscle that acts synergistically with the target muscle to simplify and facilitate postoperative rehabilitation and motor re-education. If no other options are available, a nerve branch to a muscle that is not synergistic or even antagonistic may be transferred, but postoperative therapy will be more difficult and less intuitive and may lead to a less optimal result. Nerve transfers have several advantages over tendon transfers, including minimal dissection around the target muscle. Such dissection may lead to scarring and limited excursion and strength.2,3 Nerve transfers are also capable of restoring sensory as well as motor function, and can reinnervate several muscles in a group with a single donor nerve. With proximal nerve injuries, a distal nerve transfer converts a high proximal lesion to a low distal injury in terms of recovery and reinnervation time. We often perform distal nerve transfers simultaneously with proximal nerve graft reconstruction to avoid the formation of a painful proximal neuroma. The choice of donor nerve is also based on the proximity to the motor endplate of the target muscle for a direct transfer using a primary repair, but a nerve graft is occasionally necessary. Internal neurolysis can often be used to obtain more length on the donor and recipient nerve branch from the main nerve to allow a primary repair whenever possible.4,5

Postoperative care Nerve conduit reconstructions should be immobilized for approximately 1 week because there should be no tension at the fixation sites throughout the full range of joint motion. Motion should then be encouraged to minimize scarring and adhesions around the repair.

NERVE TRANSFERS OF THE UPPER EXTREMITY Nerve transfers have conventionally been reserved for severe root avulsion injuries of the brachial plexus in which reconstruction with nerve grafts is not possible.1 Even when a root stump is available, the use of nerve grafts for such proximal injuries is frequently associated with a poor outcome because of the long distance over which nerve regeneration must occur to reach target muscles. To improve outcomes in this group of patients, the technique of nerve transfer was applied as a natural extension of the use of tendon transfers and the principles of motor re-education and rehabilitation. As our experience with nerve transfers has increased and we have observed better functional results, we have used this technique with increasing frequency in a broader range of patients, including those with more distal and isolated nerve trauma and those for whom tendon transfers is conventionally recommended. The advantages typically include less operative time, less morbidity and shorter recovery times, and faster target muscle reinnervation with less atrophy and motor endplate fibrosis.

Indications and timing Because of the excellent results that can be obtained from nerve transfer, we advocate its use in almost any case in which regeneration distance and time to reinnervation can be significantly reduced to improve outcome. It is also used to avoid surgery under unfavorable tissue conditions,

238 Hand and Upper Extremity Reconstruction especially when other critical structures have already been reconstructed, for example vascular injuries. Currently, our recommendations include the following: ● Brachial plexus injuries in which only very proximal or no nerve is available for grafting. ● High proximal injuries that require a long distance for regeneration. ● Avoidance of scarred areas in critical locations with potential for injury to critical structures. ● Major limb trauma with segmental loss of nerve tissue. ● As an alternative to nerve grafting when time from injury to reconstruction is prolonged. ● Partial nerve injuries with a defined functional loss. ● Spinal cord root avulsion injuries. ● Nerve injuries in which the level of injury is uncertain, such as with idiopathic neuritides or radiation trauma and nerve injuries with multiple levels of injury. Recovery of motor function depends on a critical number of motor axons reaching the target muscle to reinnervate muscle fibers within a critical period. In adults, reinnervation of denervated muscles is generally not possible after 12–18 months because of degeneration of the motor endplates. Axonal regeneration occurs at a rate of 1 inch/month, or 1–1.5 mm/day.6 The use of distal nerve transfers can significantly prolong the ‘window’ of opportunity for surgical intervention after injury. A distal nerve transfer within centimeters of the neuromuscular junction of the target muscle will still have the potential for successful reinnervation even if performed late (8–10 months) after the injury.

NERVE TRANSFERS FOR MEDIAN NERVE PALSY Indications ●

Isolated functional deficits of forearm pronation, thumb opposition, or finger flexion within 8 months of the inciting event.


Functional deficit of a duration of 1 year or more.

Preoperative considerations We have used motor nerve transfers reliably to restore pronation, thenar muscle function, and flexor pollicis longus (FPL) function. If loss of pronation exists as an isolated deficit, a redundant or expendable branch from the ulnar or median nerve itself may be used to reinnervate the pronator teres (see Operative Approach for Pronation, below).24 The branches (usually two) to the pronator are found proximally at the level of the antecubital fossa. Nerve stimulation is used to identify the multiple branches of the median nerve. There are usually two or more branches to the FDS, and one or two can be transferred directly to the branches of the pronator teres by direct repair. The pollicis longus (PL), if present, or flexor carpi radialis (FCR) branches may

also be used. If the median nerve is not available to provide donor motor axons, then a redundant branch to the flexor carpi ulnaris (FCU) from the ulnar nerve can be used. In the case of combined ulnar and median nerve palsy with intact shoulder and elbow function, such as in C8–T1 avulsions, we prefer to transfer the extensor carpi radialis brevis (ECRB) and supinator branches of the radial nerve to the pronator teres branch and anterior interosseous nerve (AIN). If these branches are not available, and the FCU muscle is functional, a redundant FCU branch of the ulnar nerve can be used. This will require a separate incision over the course of the ulnar nerve for its anterior transposition to facilitate a direct tension-free transfer. We have also transferred the brachioradialis branch of the radial nerve to the proximal AIN, with either a medial antebrachial cutaneous (MABC) or medial brachial cutaneous (MBC) nerve graft to restore finger flexion. Thumb opposition can be effectively corrected with standard tendon transfers; however, the terminal AIN at the wrist may be used to reinnervate the motor branch of the median nerve with a short nerve graft. In the case of an isolated palsy of the FPL, another expendable motor branch of the median nerve, such as that to the PL, FDS or FCR, may be used as donor axons for transfer to the FPL branch.

Operative approach for pronation A longitudinal volar incision is used to expose the median nerve, and the branches to the pronator teres are identified as the most proximal. A nerve stimulator is used to verify loss of function to the pronator teres, and these branches are divided as far proximally as possible. An FDS or PL branch is the preferred donor nerve for transfer, and these are dissected as far distally to the muscle as possible. A direct repair is performed using standard microneurosurgical technique (Fig. 17.7). The forearm is pronated and supinated prior to the repair to ensure a tension-free repair. The wound is closed in layers, usually with insertion of a pain pump and a drain. A posterior splint with the elbow flexed to 90º is used, leaving the fingers, wrist and shoulder free. On postoperative day 2 the splint, drains and pain pump are removed, and the patient is placed in a protective sling for an additional 2 weeks.

Operative approach: radial-to-median nerve transfer A longitudinal incision is made in the proximal volar forearm just below the antecubital fossa in the lateral third of the forearm. We perform a step-cut lengthening of the pronator teres tendon to decompress and facilitate exposure of the median nerve. Its branches are identified and dissected, and loss of function is verified. The critical target motor branches are those to the pronator teres and the AIN. Lateral dissection is then carried out beneath the wrist extensors to expose the radial nerve. The ECRB branch is readily identified and verified using a standard nerve stimulator, but exposure of the supinator branch for transfer will


Median nerve

Median nerve

Median nerve

ECRB branch FCR and Palmaris longus branches

PIN

Pronator teres branch

Supinator branch

Pronator teres branches

Sensory branch

AIN

FDS branch

FIGURE 17.7 Nerve transfer reconstruction for pronation. Redundant motor branch to flexor digitorum superficialis (FDS) is transferred directly to the pronator branch of the median nerve. Portions of the flexor carpi radialis (FCR) or palmaris longus branches could also be used.

require further distal dissection and splitting of the supinator muscle. These branches are then divided as distally as possible, and the target median nerve branches are divided as proximally as possible to allow direct coaptation of the appropriate nerve branches (Figs 17.8, 17.9). The forearm is pronated and supinated to ensure a tension-free repair. The wound is closed in layers, usually with insertion of a pain pump and a drain. A posterior splint with the elbow flexed to 90º is used, leaving the fingers, wrist and shoulder free. On postoperative day 2 the splint, drains and pain pump are removed, and the patient is placed in a protective sling for an additional 2 weeks.

NERVE TRANSFERS FOR RADIAL NERVE PALSY Indications ●

Isolated functional deficits of wrist extension and finger, thumb extension within 8 months of the inciting event.

FIGURE 17.8 Radial-to-median nerve transfer. The radial and median nerves are exposed through the same incision in the volar proximal forearm. Proximal motor branches of the radial nerve including the extensor carpi radialis brevis (ECRB) and supinator motor branches, and the median nerve including the pronator teres and anterior interosseous nerve (AIN) branches are mobilized. A direct transfer is performed from the ECRB to pronator branches, and the supinator branch to the AIN.


Functional deficit of 1 year or more duration.

Preoperative considerations Motor branches of the median nerve are available and in close proximity to the radial nerve for use as donor nerves for transfer (Fig. 17.10). Expendable motor branches with minimal or no donor morbidity include the palmaris longus branch, a portion or all of the FCR branches, and a redundant flexor digitalis superioris (FDS) branch. All are readily identified and dissected in the proximal forearm. The use of a donor nerve branch from a muscle that is synergistic to the target muscle will facilitate postoperative therapy and motor re-education. However, a nerve from a non-synergistic muscle or even an antagonistic muscle (less ideal) to the target muscle can be used. Motor re-education will be more difficult for the patient, however, and the use of additional


Radial nerve

ECRB branch Sensory branch

A

B FIGURE 17.9 A Wide exposure of volar proximal forearm with vessel loops around radial and median nerve branches. B Direct end-to-end transfer of ECRB to pronator branch, and supinator branch to AIN.

assistance such as audio and/or visual biofeedback may help to correctly recruit the target muscles and to minimize co-contraction of the antagonistic muscles. Nevertheless, an excellent functional result is still possible for a compliant patient with a good understanding of the motor reeducation strategies and appropriate hand therapy. Whereas median and radial nerve functions are non-synergistic, certain movements are complementary based on the tenodesis effect. Wrist extension increases the passive tension of the flexor tendons and thereby passively causes finger flexion and augments flexion strength, whereas wrist flexion has the opposite effect. Because of this, the use of a donor nerve branch that innervates finger flexion (FDS) rather than wrist flexion (FCR/PL) is complementary for wrist extension (ECRB). Similarly, a donor nerve branch that innervates wrist flexion (FCR) is better suited for finger extension (posterior interosseous nerve (PIN)). Wrist extension also requires greater force than finger extension. The excellent functional results we have seen with this nerve transfer are also due in part to the relatively

PIN

Median nerve

Redundant FDS branch

FCR/PL branch

FIGURE 17.10 Median-to-radial nerve transfer. Similar exposure of radial and median nerve branches in proximal forearm through single longitudinal incision. Motor branch to FDS, FCR or palmaris longus of median nerve transferred directly to ECRB and PIN branches of radial nerve.

greater number of motor axons transferred to the ECRB than to the PIN branches. There is a slight size match discrepancy between the two nerve branches, the PIN being larger than the ECRB branch. By contrast, the two donor branches from the median nerve are similar in size. Thus the wrist extensor reinnervates a relatively greater percentage of motor axons.

Operative approach: median-to-radial nerve transfer An incision is made in the proximal volar forearm just below the antecubital crease. The median nerve and its branches are identified deep beneath the flexor/pronator muscles with intraoperative nerve stimulation, including those to the FDS, FCR, and palmaris longus (PL), the anterior interosseous (AIN) and the main median nerve (Fig. 17.11). Through the same incision, the radial sensory nerve is identified laterally beneath the mobile wad muscles and followed proximally to identify the target motor branches, the PIN and the branch to the ECRB. In preparation for


FIGURE 17.11 Proximal exposure of median nerve just below elbow with vessel loops around AIN, FDS and FCR/PL motor branches.

nerve transfer, the radial nerve branches to the ECRB and the PIN are divided as proximally as possible to maximize length for the transfer. The branch to the FDS and the FCR/PL branch of the median nerve are then divided as distally as possible to allow a direct tension-free end-to-end coaptation to the ECRB branch and the PIN, respectively, using standard microneurosurgical technique (Fig. 17.12). Transection of the supinator branch of the radial nerve will facilitate transposition and provide longer reach of the PIN towards the median nerve for a direct nerve transfer.

FIGURE 17.12 Radial and median nerve branches divided and transposed for transfer of FDS to ECRB branch and palmaris longus or part of FCR to PIN.

Radial digital nerve of index

SENSORY NERVE TRANSFERS Restoring sensation to the hand is essential for optimal functional reconstruction, and sensory nerve transfers may be performed primarily or secondarily at the level of the distal forearm or hand in conjunction with motor nerve transfers. Transfer at a distal level converts a high-level injury to a low-level one and permits a more rapid recovery of sensation to facilitate postoperative therapy and motor re-education. The ulnar nerve can be used to restore more critical median nerve sensation in high median nerve injuries, and the nerve transfer can be performed at the level of the hand as a direct nerve transfer. The common and proper digital nerves are dissected in the palm to the level of the web space, and the nerve branch to the fourth web space proximally is transferred directly to the branch to the first web space distally in an end-to-end fashion (Fig. 17.13). Non-critical sensation of the long and ring fingers can be improved by transfer in an end-to-side fashion to the functional digital branches of the ulnar nerve to restore protective sensation, with no donor morbidity to the ulnar nerve (Fig. 17.14). The branch to the third web space can also be used to restore more critical border digit sensation in a

4th web sensory nerve

Ulnar digital nerve of thumb

FIGURE 17.13 Sensory transfer of ulnar common digital nerve to the fourth web space to the first web space in median nerve injury to restore critical digital sensation.

242 Hand and Upper Extremity Reconstruction coaptation sites. The fascicular transfer technique at the wrist has the advantage of avoiding incisions on the palm, avoiding potential injury to the palmar vascular arches, and can be combined with other procedures typically performed at the wrist or distal forearm.

Optimizing outcomes: motor and sensory re-education

Ulnar digital nerve of small finger 2nd and 3rd web sensory nerves

The long-term focus of rehabilitation is on motor and/or sensory re-education. As with tendon transfers, the patient must learn and be able to coordinate synchronized movement. Following nerve transfer, the cortical command required to initiate target muscle contraction is different from that previously experienced. The patient ‘relearns’ motor control of the reinnervated target muscle by activating the nerve to the donor muscle, which now stimulates the reinnervated muscle (see Fig. 17.8).5 This concept is similar to the re-education needed after tendon transfers. In addition, the ability to restore sensation can only improve recovery, but does not guarantee optimal function. Sensory re-education begins when the patient begins to perceive input stimulus from the reinnervated territory. Cortical remapping occurs from continued sensory input from the newly innervated areas.

CONCLUSIONS FIGURE 17.14 For non-critical digit sensation following median nerve injury, end-to-side transfer of common digital nerves to the second and third web spaces to the functioning digital nerve branches of the ulnar nerve will restore protective sensation with essentially no donor morbidity.

similar manner in the palm, or a sensory fascicular transfer technique at the level of the wrist and distal forearm can be performed. Because the internal topography of the median and ulnar nerves at that level is well established, the fascicular components of each nerve are readily identified and dissected. In particular, the fascicle to the third web space is readily dissected from the median nerve to the level of the mid-forearm. However, the sensory components of the ulnar nerve to the fourth web space and to the ulnar border of the small finger are not readily separable at this level. Therefore, we prefer dissection in the hand when using only the fourth web space branch as donor nerve, and fascicular transfer at the distal forearm when using the whole sensory component of the ulnar nerve to the hand as the recipient or donor nerve. When performing internal neurolysis of the median nerve, usually four fascicular groups are easily dissected, with the group innervating the third web space located the most medially. In the ulnar nerve at the wrist, the motor fascicle is located medially and the sensory fascicles make up the lateral half. As with all nerve transfers, the donor fascicle or nerve branch is divided as distally as possible, and the recipient fascicle or nerve branch is divided as proximally as possible to maximize length for transposition and minimize tension at the

Over the last century, significant advances in peripheral nerve surgery have been made. The introduction of microsurgery has transformed nerve surgery into a sophisticated specialty with techniques that produce consistent results. The combined experience from brachial plexus surgery, tendon transfers, and motor and sensory re-education has allowed the development of nerve transfer techniques as a reliable surgical option for the reconstruction of nerve injuries. In the last decade, reconstruction of upper plexus injuries in our institution has progressed from the use of long nerve grafts to distal elegant nerve transfers. The need to expose and explore the brachial plexus is reserved for tumor cases and other special circumstances. Our use of nerve transfers far removed from the zone of injury allows us to restore function and sensibility in shorter operative time, through smaller incisions, with less morbidity, and to achieve comparable or better functional results than in the past.

REFERENCES 1. Harris W, Low VW. On the importance of accurate muscular analysis in lesions of the brachial plexus. Br Med J 1903; 2: 1035. 2. Guelinckx PJ, Faulkner JA. Parallel-fibered muscles transplanted with neurovascular repair into bipennate muscle sites in rabbits. Plast Reconstruct Surg 1992; 89: 290–298. 3. Guelinckx PJ, Carlson BM, Faulkner JA. Morphologic characteristics of muscles grafted in rabbits with neurovascular repair. J Reconstruct Microsurg 1992; 8: 481–489. 4. Dvali L, Mackinnon S. Nerve repair, grafting, and nerve transfers. Clin Plastic Surg 2003; 30: 203–221.

Nerve Reconstructive Techniques in the Hand 243 5. Mackinnon SE, Novak CB. Nerve transfers: new options for reconstruction following nerve injury. Hand Clin 1999; 15: 643–666. 6. Seddon HJ, Medawar PB, Smith H. Rate of regeneration of peripheral nerves in man. J Physiol 1943; 102; 191–201. 7. Leffert RD. Brachial Plexus. In: Green DP, ed. Operative hand surgery, 4th edn. Philadelphia: Churchill Livingstone, 1999; 1557–1587. 8. Tsuge K, Kanaujia RR, Steichen JB. Functional restoration in brachial plexus injury. In: Steichen JB, ed. Comprehensive atlas of hand surgery. Chicago: Year Book Medical Publishers, 1989; 564–578. 9. Merrell GA, Barrie KA, Katz DL, Wolfe SW. Results of nerve transfer techniques for restoration of shoulder and elbow function in the context of a meta-analysis of the English literature. J Hand Surg 2001; 26A: 303–314. 10. Brandt KE, Mackinnon SE. A technique for maximizing biceps recovery in brachial plexus reconstruction. J Hand Surg 1993 18A: 726–733. 11. Oberlin C, Béal D, Leechavengvongs S, et al. Nerve transfer to biceps muscle using a part of ulnar nerve for C5-C6 avulsion of the brachial plexus: anatomical study and report of four cases. J Hand Surg 1994 19A: 232–237. 12. Leechavengvongs S, Witoonchart K, Uerpairojkit C, et al. Nerve transfer to biceps muscle using a part of the ulnar nerve in brachial plexus injury (upper arm type): a report of 32 cases. J Hand Surg 1998; 23A: 711–716. 13. Sungpet A, Suphachatwong C, Kawinwonggowit V, Patradul A. Transfer of a single fascicle from the ulnar nerve to the biceps muscle after avulsions of upper roots of the brachial plexus. J Hand Surg 2000; 25B: 325–328. 14. Humphreys DB, Mackinnon SE. Nerve transfers. Op Tech Plast Reconstruct Surg 2002; 9: 89–99. 15. Tung TH, Novak CB, Mackinnon SE. Nerve transfers to the biceps and brachialis branches to improve elbow flexion strength after brachial plexus injuries. J Neurosurg 2003; 98: 313–318. 16. Brandt KE, Mackinnon SE. Microsurgical repair of peripheral nerves and nerve grafts. In: Aston SJ, Beasley RW, Thorne CHM, eds. Grabb and Smiths’ plastic surgery, 5th edn. New York: Lippincott-Raven, 1997; 79–90. 17. Jabaley ME, Wallace WH, Heckler FR. Internal topography of major nerves of the forearm and hand: a current view. J Hand Surg 1980; 5A: 1–18. 18. Watchmaker GP, Gumucio CA, Crandall RE, et al. Fascicular topography of the median nerve: a computer based study to identify branching patterns. J Hand Surg 1991; 16A: 53–59.

19. Vallejo GI, Toh S, Arai H, et al. Results of the latissimus dorsi and teres major tendon transfer on to the rotator cuff for brachial plexus palsy at birth. Scand J Plast Reconstruct Surg Hand Surg. 2002; 36: 207–211. 20. Novak CB, Mackinnon SE. Treatment of a proximal accessory nerve injury with a nerve transfer. Laryngoscope 2004; 114(8): 1482–1484. 21. El Gammal TA, Fathi NA. Outcomes of surgical treatment of brachial plexus injuries using nerve grafting and nerve transfers. J Reconstruct Microsurg 2002; 18: 7–15. 22. Leechavengvongs S, Witoonchart K, Uerpairojkit C, Thuvasethakul P. Nerve transfer to deltoid muscle using the nerve to the long head of the triceps, part II: a report of 7 cases. J Hand Surg 2003; 28A: 633–638. 23. Lowe JB 3rd, Tung TR, Mackinnon SE. New surgical option for radial nerve paralysis. Plast Reconstruct Surg 2002; 110: 836–843. 24. Tung TH, Mackinnon SE. Flexor digitorum superficialis nerve transfer to restore pronation: two case reports and anatomic study. J Hand Surg 2001; 26A: 1065–1072. 25. Stuebe AM, Novak CB, Mackinnon SE. Recovery of ulnar nerve innervated intrinsic muscles following anterior transposition of the ulnar nerve. Cancer J Plast Surg 2001; 9: 25–28. 26. Lester RL, Smith PJ, Mott G, McAllister RM. Intrinsic reinnervation – myth or reality? J Hand Surg 1993; 18B: 454–460. 27. Novak CB, Mackinnon SE. Distal anterior interosseous nerve transfer to the deep motor branch of the ulnar nerve for reconstruction of high ulnar nerve injuries. J Reconstruct Microsurg 2002; 18: 459–464. 28. Wang Y, Zhu S. Transfer of a branch of the anterior interosseus nerve to the motor branch of the median nerve and ulnar nerve. Chin Med J 1997; 110: 216–219. 29. Steffensen I, Dulin MF, Walters ET, Morris CE. Peripheral regeneration and central sprouting of sensory neurone axons in Aplysia californica following nerve injury. J Exp Biol. 1995; 198: 2067–2078. 30. Lesavoy MA, Dubrow TJ, Eisenhauer DM, et al. A new nerve pedicle for finger sensibility: the dorsal digital sensory nerve. Plast Reconstruct Surg 1993; 9: 295–298. 31. Tarasidis G, Watanabe O, Mackinnon SE, et al. End-to-side neurorrhaphy: a long-term study of neural regeneration in a rat model. Otolaryngol Head Neck Surg 1998; 119: 337–341. 32. Tarasidis G, Watanabe O, Mackinnon SE, et al. End-to-side neurorrhaphy resulting in limited sensory axonal regeneration in a rat model. Ann Otol Rhinol Laryngol. 1997; 106: 506–512. 33. Koshima I, Nanba Y, Tsutsui T, Takahashi Y. Deep peroneal nerve transfer for established plantar sensory loss. J Reconstruct Microsurg 2003: 19: 451–454.

CHAPTER

Brachial Plexus Reconstructive Techniques

18

Lynda Yang and Kevin C. Chung

INTRODUCTION Brachial plexus injuries lead to paresis or paralysis of the upper extremity. Motor vehicle accidents cause approximately 70% of adult brachial plexus injuries (BPI),1 and such injuries lead to significant socioeconomic difficulties for these newly disabled patients who are usually 15–25year-old males.2–4 As the number of accidents from highspeed motor vehicle collisions and dangerous sporting events increases, the prevalence of BPI is also increasing worldwide.3,5–9 The care of patients with BPI continues to evolve: outcomes will be enhanced by improvements in surgical techniques, by advances in nerve regeneration research, and by the development of novel pharmacological agents. This chapter presents the key concepts underlying the current surgical management of BPI. Appropriate surgical management of patients with brachial plexus injuries depends on an understanding of the physiology of nerve injury/regeneration and brachial plexus anatomy. In 1943, Seddon10 proposed a system for classifying nerve injury that is still useful today; this system consists of neurapraxia, axonotmesis, and neurotmesis (Fig. 18.1). Neurapraxia refers to the segmental interruption of the myelin sheaths, leaving the axons and surrounding connective tissues intact; this type of injury recovers spontaneously within a few weeks. Axonotmesis refers to the interruption of both the myelin sheath and the axons, but with sparing of the surrounding connective tissues (intact Schwann cell basal lamina): this injury may recover spontaneously within months to years if axonal regeneration is able to progress across the injury zone. Neurotmesis refers to the interruption of all of the elements, including the axons, the myelin sheaths, and the surrounding connective tissues; spontaneous recovery does not occur. To select the appropriate timing for diagnostic electrophysiologic studies, one must recognize the concept of Wallerian degeneration. When the structure of the axon is disrupted, the neuron itself is damaged; the distal portion

of the axon, which is disconnected from the cell body, undergoes granular disintegration of the cytoskeleton and axoplasm over several days to weeks. Early after injury, until the distal axons are totally degenerated, motor conductivity and/or sensory nerve potentials still can be observed. Therefore, electrodiagnostic studies used to predict the severity of the lesion and to guide treatment recommendations should not be performed within several weeks of the injury. Regeneration of the interrupted axon towards its correct muscular target depends on guidance by the basal Schwann cell lamina (axonotmesis) or grafted basal lamina (neurotmesis). The axons of the proximal stump will sprout, and a growth cone leads each sprout. The distal stump degenerates, and axonal and myelin debris will be cleared away by macrophages (Wallerian degeneration) to prepare the distal stump for reception of the outgrowing axonal sprouts. The ‘growing point’ of the regenerating axons can produce paresthesias when tapped (Tinel’s sign). When the outgrowing stump of axonal growth cones is halted by scar tissue at the point of injury, a neuroma forms. Functional recovery relies on regenerating axons that can grow to reach their target muscle before the denervated muscle degenerates. Unfortunately, the rate of axonal regeneration is quite slow, at approximately 1 mm/day. Therefore, axonotmetic injury to the supraclavicular brachial plexus requires months to years before the recovering axon reaches the distal musculature. After long periods of denervation, the distal musculature will have degenerated and the joints may develop contractures. Research into expediting nerve regeneration is under way, but adjunctive pharmacologic agents to enhance nerve regeneration are not yet ready for clinical use. Another key to understanding the operative management of BPI is a thorough understanding of the normal anatomy of the brachial plexus. The brachial plexus is comprised of the nerve structures by which the central

245

246 Hand and Upper Extremity Reconstruction Neurapraxia

Basement membrane

Axon

Myelin sheath

Branches Cords Divisions Trunks

Roots

C4 C6 Axonotmesis

T1

Neurotmesis

FIGURE 18.1 Seddon’s classification of nerve injury: neurapraxia, axonotmesis, neurotmesis.

nerve system communicates with the upper extremity. It has five roots (C5–T1), three trunks (upper, middle, and lower), six divisions (two divisions, anterior and posterior, per trunk), three cords (lateral, posterior and medial), and five terminal nerve branches (musculocutaneous, radial, axillary, median, and ulnar; Fig. 18.2). Grossly, the brachial plexus emerges in the posterior triangle of the neck (bordered by the sternocleidomastoid, trapezius, clavicle and occiput; Fig. 18.3) Note that the spinal accessory nerve emerges posterior to the sternocleidomastoid, two-thirds of the way up from the sternum to the mastoid, and travels relatively superficially towards the trapezius. More specifically, the trunks of the brachial plexus emerge within the interscalene triangle bordered by the anterior scalene, middle scalene, and the clavicle (Fig. 18.4). The subclavian artery also travels through the interscalene triangle, whereas the subclavian vein travels anterior to the anterior scalene. The nerve roots contributing to the trunks exit from their neural foramina and run along the bony groove between the anterior and posterior tubercles of the vertebrae. These bony ‘chutes’ are well formed for the nerves comprising the upper trunk (C5, C6), and more abbreviated for the nerves comprising the lower trunk. In addition, there is less connective tissue binding the lower nerve roots to the bony chutes than in the upper nerve roots. Consequently, the lower nerve roots (C8, T1) are prone to preganglionic (avulsion) injury, whereas the nerves comprising the upper trunk tend to sustain postganglionic injury. The anterior scalene attaches to the anterior tubercle of the transverse process of the vertebrae and the clavicle, and the middle scalene attaches to the posterior tubercle of the transverse process; the anterior tubercle of C6 is particularly bulbous (Chassignac’s tubercle) and can be used as an intraoperative marker. The brachial plexus is intimately associated with prominent vasculature. In the supraclavicular region, the subclavian vessels are in close proximity to the lower roots/lower trunk. In the infraclavicular region the cords surround the axillary artery, and in the arm the median nerve travels with the brachial artery.

FIGURE 18.2 Brachial plexus: five roots (C5–T1), three trunks (upper, middle, lower), six divisions (anterior and posterior divisions per trunk), three cords (lateral, posterior, medial), and five branches (musculocutaneous, radial, axillary, median, ulnar.)

Sternocleidomastoid muscle

Middle scalene muscle Accessory nerve

Trunks of brachial plexus

Anterior scalene muscle Phrenic nerve

FIGURE 18.3 Brachial plexus emerging from the posterior triangle of the neck.

Brachial Plexus Reconstructive Techniques 247 propose an algorithm for the surgical management of peripheral nerve and brachial plexus injuries (Fig. 18.5).

PREOPERATIVE HISTORY AND CONSIDERATIONS

Well-formed “chute”

Middle scalene Anterior scalene Brachial plexus Subclavian artery First rib

FIGURE 18.4 Brachial plexus emerging from the interscalene triangle.

INDICATIONS AND CONTRAINDICATIONS FOR SURGERY Understanding the indications and contraindications for surgical management of BPI depends on understanding the type of injury. Brachial plexus injuries can be classified in several ways. Anatomically, they can be considered to be supraclavicular (roots, trunks), retroclavicular (divisions), and infraclavicular (cords, terminal branches). Most injuries occur to the roots and trunks in the supraclavicular region. Supraclavicular injuries can also be classified as preor postganglionic, with profound surgical implications. A preganglionic injury results in permanent paralysis of the muscles innervated by the avulsed roots, complete sensory loss of the corresponding dermatomes, and most importantly, the lack of spontaneous recovery. A postganglionic injury potentially retains the function of the cell body within the ventral horn of the spinal cord, and under the appropriate conditions these neurons may regenerate axons. Brachial plexus injury can be open or closed. Open injuries include sharp lacerations and missile wounds, whereas closed injuries include traction or compressive injuries. Current guidelines recommend early repair of clean sharp nerve lacerations, and the delayed (by weeks) repair of ragged or dirty nerve lacerations. Missile wounds with vascular injury should be explored acutely. Early intervention is generally not recommended in closed injuries because of the potential for neurapraxia. Spontaneous regeneration, when it occurs, yields superior functional outcomes compared to surgical repair or reconstruction. Consideration of the clinical implications of these issues led Kline11 to

When considering surgical treatment, the surgeon ought to weigh the potential benefits versus the impending risks of the operation. Estimation of the risk–benefit ratio of the treatment requires careful history taking and a detailed physical examination. Well-intentioned but inappropriate procedures can result in worsening symptoms or creating new deficits. The following is not meant to describe a comprehensive neurological examination of the upper extremity peripheral nerve system (refer to Aids to the Examination of the Peripheral Nerve System12), but will provide a few pearls ‘for guidance’. The history should include the patient’s description of the timing and quality of the motor and sensory deficits, pain, paresthesias, other symptoms, and also the mechanism of injury. For example, a road rash over the shoulder may point towards an injury resulting from traction of the brachial plexus when the arm is distracted in the opposite direction of the head, which implies injury to the upper brachial plexus (Erb’s palsy). In contrast, a road rash on the underside of the arm, axilla, and/or side of torso points towards an injury that results from traction of the arm in the fully abducted position, implying injury to the lower brachial plexus (Klumpke’s palsy). Likewise, a similar acute presentation from falling 3 feet (more consistent with neurapraxia) versus ejection from a high-speed motor vehicle has very different implications for treatment. The physical examination can be categorized as follows. A vascular assessment for the presence of peripheral pulses must be performed. Inspection of the affected limb can reveal changes in skin turgor and coloration, which may point towards denervated dermatomes. A comprehensive assessment of the musculature, coupled with a thorough understanding of brachial plexus anatomy, can lead to an accurate determination of the identity and the severity of injured nerves and their anatomic level of involvement. Although the spinal accessory nerve is not considered to be part of the brachial plexus, examination of trapezius function will determine whether the spinal accessory nerve can be a potential donor in future neurotization procedures. Diaphragmatic function should be assessed by plain radiograph or ultrasound, because denervation of the diaphragm can imply a preganglionic lesion. The sensory examination can confirm the suspicion of the relevant lesion, and the quality of the extremity pain can aid in the localization of the lesion. For example, constant aching can indicate deafferentation pain, which accompanies an avulsion injury, whereas sharp, stabbing pains are more consistent with postganglionic lesions. The presence of Horner’s syndrome (an interruption of sympathetic fibers marked by constricted pupil, drooping eyelid, and lack of sweating on the face) is consistent with a preganglionic lesion. Serial palpation and percussion along the suspected path of the injured nerve can detect a distally traveling Tinel’s sign of neural regen-

248 Hand and Upper Extremity Reconstruction FIGURE 18.5 Algorithm for the surgical management of peripheral nerve and brachial plexus injuries.

Brachial plexus injury

Open injury

Closed injury

Laceration/ transection

Lesion in continuity from stretch/contusion. Compression, ischemic, electric, injection, or latrogenic injury

Sharp Nerve divided sharply

Blunt Nerve contused Epineureum ragged

Primary or early repair (within 3 d)

"Tack" to adjacent tissue planes Secondary repair at 3 wks

Evaluation

Clinical assessment, EMGs, Radiographs, CT-myelogram, MRI

No regeneration (No recovery)

Regeneration (Recovery)

Exploration, Repair/Reconstruction With intraoperative monitoring, >3 months

eration. Finally, examination of the range of motion of the joints of the upper extremity can detect joint contractures and signify the need for more aggressive physical therapy. Electrodiagnostic studies (EDS) can aid in defining the site of injury and the potential for reinnervation of affected musculature. Baseline EDS are best performed 3 or more weeks after injury. Serial EDS can document clinically significant regeneration. Lack of innervation of paraspinal muscles implies a proximal injury within the brachial plexus. Sensory nerve action potentials (SNAPs) and somatosensory evoked potentials (SSEPs) are also useful in determining the site of injury. Radiographic studies should include cervical spine and chest radiographs, which may reveal associated fractures of the cervical vertebrae, clavicle, scapula or ribs, and demonstrate an elevated hemidiaphragm (phrenic nerve injury). Post-myelography computerized tomography (CT) and MRI can be used to detect pseudomeningoceles, which may be associated with preganglionic injuries and require extraplexal nerve transfer procedures. The resolution provided by current standard imaging techniques is as yet unable to demonstrate direct evidence for the interruption of nerve structures. When operative treatment is contemplated, the surgeon should gauge the patient’s expectations. Similarly, the patient should understand the reconstructive priorities when spontaneous recovery of function is unlikely. Patience is needed from both patient and practitioner. Most sur-

geons consider restoration of elbow flexion to be of the highest priority. Shoulder abduction and stability, hand sensibility, wrist extension and finger flexion, wrist flexion and finger extension, and intrinsic function of the hand follow in order of priority.13,14

OPERATIVE APPROACH The successful brachial plexus operation depends on not only a thorough understanding of the nerve connections within the plexus, but also on the vital structures surrounding the brachial plexus.

Supraclavicular exposure The supraclavicular brachial plexus is exposed in the posterior triangle of the neck (Fig. 18.6, black arrow). The patient is supine, with a roll under the scapulae and the head turned towards the opposite direction with the neck in gentle extension (Fig. 18.6). If there is a need to acquire a sural nerve graft, a roll is also placed under the buttock to internally rotate and flex the ipsilateral leg. The lower part of the face, neck, shoulder, entire chest and leg are prepared for surgery. A curvilinear incision extending from the sternocleidomastoid to the trapezius is made approximately 1.5 cm above the clavicle. The platysma is incised perpendicular to its fibers, and a generous subplatysmal dissection is per-

Brachial Plexus Reconstructive Techniques 249 formed. The external jugular vein is often encountered and must be retracted or ligated when necessary. The position of the spinal accessory nerve is relatively superficial as it courses from the posterior aspect of the sternocleidomastoid muscle (two-thirds of the distance from the sternum to the mastoid) towards its insertion in the trapezius (Fig. 18.7). Identification of the spinal accessory nerve along its course is crucial to preserve trapezius function and to use its branches for a donor for nerve transfer. An intraoperative nerve stimulator can be used to identify and confirm this nerve. The lateral margin of the sternocleidomastoid muscle is identified, with its sternal and clavicular heads. The lateral aspect of the clavicular head is released to facilitate exposure. The supraclavicular nerves (sensory nerve branches of the ansa cervicalis, C2–C4) are identified along their super-

FIGURE 18.6 Incisions. Black arrow indicates incision for supraclavicular approach to brachial plexus. Red arrow indicates standard deltopectoral approach to the infraclavicular brachial plexus.

ficial craniocaudal course and likewise preserved for anatomical landmarks and as potential donors for nerve graft material. The supraclavicular nerves are followed proximally until the C4 spinal nerve root is identified; a branch from this nerve can be followed to the phrenic nerve, which derives from C3, C4, and C5. The phrenic nerve is dissected along its length on the anterior aspect of the anterior scalene muscle. One should carefully mobilize the phrenic nerve to preserve the function of the diaphragm. Periodic stimulation of the nerve with an intraoperative nerve stimulator will confirm the intraoperative integrity of the nerve. The lateral edge of the anterior scalene muscle is identified. The scalene fat pad is released from this border in a cranial to caudal direction, then in a medial to lateral direction to reflect the fat pad laterally. When releasing the fat pad deep in this region during the exposure of the left supraclavicular brachial plexus, one should preserve or ligate the thoracic duct to avoid chyle leakage. The omohyoid muscle is identified along its course toward the suprascapular notch, and can be tagged and divided. Note that preserving this muscle to identify the suprascapular notch can facilitate the identification of the suprascapular nerve (see below), especially in patients whose anatomy is distorted by trauma. The phrenic nerve courses lateral to medial toward the diaphragm, whereas the contents of the plexus and the surrounding nerves course from medial to lateral. As the phrenic nerve approaches the lateral edge of the anterior scalene, the C5 spinal nerve root emerges (Fig. 18.8). Following the C5 root distally leads to the upper trunk, and following the upper trunk proximally will lead to the C6 spinal nerve root. The C6 spinal nerve root is located caudal and dorsal to the C5 spinal nerve root. The anterior tubercle of C6 is very prominent (Chassignac’s tubercle). The C7, C8, and T1 spinal nerve roots are sequentially more caudal and dorsal. The transverse cervical artery and vein cross the C7 spinal nerve root and can be ligated.

Anterior scalene

Phrenic nerve

C5

Upper trunk

FIGURE 18.7 Spinal accessory nerve in its superficial course from the sternocleidomastoid to the trapezius.

FIGURE 18.8 C5 root emerging at the junction of the phrenic nerve with the lateral edge of the anterior scalene.


Infraclavicular exposure

Anterior division

Posterior division

CN XI

Suprascapular n.

FIGURE 18.9 The suprascapular nerve and the divisions of the upper trunk.

Following the C7 spinal nerve distally will reveal the middle trunk. The C8 and T1 spinal nerves combine quickly to form the lower trunk, which is adjacent to the subclavian vessels. The roots of the lower trunk surround the first rib; therefore, care should be taken to avoid injury to the pleura. Should more proximal exposure of the nerve roots be necessary, the lateral edge of the anterior scalene muscle and the bony ‘chutes’ conducting the spinal nerve roots can be resected. Occasionally, clear fluid may be observed during the proximal exposure of the spinal nerve roots, indicating the presence of a pseudomeningocele and probably an avulsed root. The next step is to identify the suprascapular nerve and the divisions of the upper trunk. The upper trunk can be seen to ‘split’ into three separate structures: from lateral to medial the suprascapular nerve, the posterior division, and the anterior division (Fig. 18.9). The divisions of the brachial plexus can often be exposed by downward retraction of the clavicle. Should a more extensive exposure of the divisions be necessary, a clavicle osteotomy may be performed. A commonly encountered situation in the traumatic injury of the supraclavicular brachial plexus is an upper trunk neuroma. Following the exposure described, intraoperative nerve action potentials (NAPs) are measured. A non-conducting upper trunk neuroma is generally resected. A common strategy to repair this lesion comprises the following: (1) spinal accessory to suprascapular nerve transfer; (2) graft repair from the C5 spinal nerve to the posterior division of the upper trunk; and (3) graft repair from the C6 spinal nerve to the anterior division of the upper trunk.

The infraclavicular brachial plexus is exposed through the deltopectoral groove. The patient is placed in the supine position and a linear incision made from the clavicle toward the axilla, in line with the deltopectoral groove (see Fig. 18.6). The cephalic vein is visualized within the groove and can be retracted laterally or ligated. If needed, a portion of the pectoralis muscle can be detached from the inferior surface of the clavicle and from the humerus. The cuff of tendon from the humerus is tagged to facilitate later repair. The coracoid process of the scapula as well as the tendinous attachment of the pectoralis minor will be prominent. Blunt dissection will separate the pectoralis minor from the surrounding tissues. Once the pectoralis minor tendon has been isolated, it may be divided. It is convenient to place sutures into the tendon on either side of the divided tendon for retraction and reapproximation. Division of the pectoralis minor will reveal the infraclavicular brachial plexus lying immediately underneath. When the arm is at or lower than the plane of the shoulder, the most superficial structures are the lateral cord with its lateral branch leading to the musculocutaneous nerve and its medial branch leading to the median nerve. The medial cord may be identified medial and slightly posterior to the axillary artery, and the lateral branch of the medial cord will lead to the median nerve (the medial branch continues down the arm as the ulnar nerve). Exposure of the posterior cord and its axillary and radial nerve branches is best accomplished in the region lateral to the axillary artery.

OPTIMIZING OUTCOMES Patient selection, an understanding of their expectations, and a thorough knowledge of the anatomical caveats resulting in the thoughtful surgical planning of the repair/ reconstruction can facilitate an optimal outcome.

Diagnosis of root avulsion Diagnosing nerve root avulsion is crucial to optimize the outcome of the reconstructive strategy used in brachial plexus surgery. Currently, no single diagnostic study can provide either direct evidence of root avulsion or enough predictive value to diagnose this condition.15–18 The diagnosis of an avulsion injury should not be missed because an avulsed root eliminates the option of a direct primary repair of the relevant neural elements and necessitates the use of other reconstructive options. Available investigative modalities include computerized tomography–myelography (CT–myelography), MRI, preand intraoperative EDS, and a thorough neurologic examination. CT–myelography can document the presence of pseudomeningoceles, implying the presence of root avulsion. Rarely, the rootlets may be directly visualized; however, this study has an approximately 10% rate of false positives and false negatives.15,18 MRI of the cervical spine can also document pseudomeningoceles and occasionally may be of sufficiently high resolution to demonstrate the

Brachial Plexus Reconstructive Techniques 251 disconnected neural elements.17 Preoperative EDS include electromyography (EMG) and NAPs. Testing one muscle cannot definitively exclude root avulsion because each muscle is innervated by more than one nerve root. EMG can also demonstrate denervation of posterior myotomes, but the reliability of this finding in predicting avulsion injury varies. A more reliable electrodiagnostic modality to evaluate for avulsion injury is the absence of motor action potentials coupled with the presence of a sensory NAP from the analogous insensate dermatome. An avulsion injury will interrupt the continuity of the cells of the dorsal ganglion (sensory) to the spinal cord, but not the distal extension of the sensory axon to the periphery; therefore, somatosensory evoked potentials (SSEPs) will be absent in the presence of sensory nerve action potentials (SNAPs). Similar logic is applied to the intraoperative assessment of the SSEPs from direct stimulation of the nerve root. The absence of SSEPs in the presence of rapid NAPs provides strong evidence for an avulsion injury.19,20 Further confirmation of root avulsion results from a thorough neurological examination and knowledge of brachial plexus anatomy. The phrenic nerve, dorsal scapular nerve, and long thoracic nerve arise proximally from the roots soon after they exit the neural foramen. Consequently, a raised hemidiaphragm (phrenic nerve), paralyzed levator scapulae (dorsal scapular), and/or paralyzed serratus anterior (long thoracic nerve) imply a very proximal (potential avulsion) injury to the relevant nerve roots. The presence of ptosis, miosis, and anhydrosis of the ipsilateral face is consistent with Horner’s syndrome. Horner’s syndrome implies injury to the upper thoracic sympathetic ganglion, which is again located adjacent to the nerve root as it exits the neural foramen. Lastly, the patient’s report of deafferentation pain (continuous burning or compressive pain) will support the diagnosis of brachial plexus avulsion.

Extensile exposure Brachial plexus exploration should not be considered a minimally invasive procedure in current practice. Incomplete dissection of the appropriate plexal elements can result in a suboptimal outcome. The dissection of uninjured as well as injured nerves helps orient the surgeon when the anatomy may be distorted by the injury, and can also expose sensory nerves to be used for grafts. Identification of healthy proximal and distal recipient targets for grafts or nerve transfers is crucial to maximizing the potential for functional regeneration.21

Surgical options The knowledge of and ability to combine relevant surgical nerve repair/reconstructive options is key to achieving an optimal functional outcome. The increase in surgical options during brachial plexus operations has paralleled the advances in microsurgical techniques and the increasing availability of reliable intraoperative electrodiagnostic studies. Standard options to be considered for surgical repair or reconstructive strategy include neurolysis, direct nerve

repair, nerve repair with graft, and nerve transfers (neurotization). Neurolysis is the removal of scar tissue from around the nerve (external neurolysis) or between fascicles (internal neurolysis) if the nerve is injured asymmetrically. Dissection is begun with proximal and distal uninjured nerve ends towards the involved injured segment. Intraoperative EDS can determine whether the injured segment can conduct electric signals. The presence of nerve action potentials across an involved segment implies that neurolysis alone is adequate for neural recovery.22 Direct (end-to-end) repair is possible only if a short nerve gap exists after resection of the non-functioning neural segment. Direct repair is preferred over indirect (graft) repair because of the better functional results.22 Tension across the repair must be avoided to reduce the risk of failure of regeneration. Tension can be reduced by proximal and distal mobilization of the nerve, internal neurolysis for transposition of the involved fascicles (not recommended usually because of the scarring from the internal nerve dissection), and optimal positioning of the surrounding soft tissues/bony elements to shorten the nerve gap distance. The authors prefer the mobilization technique, for example by performing anterior transposition of the ulnar nerve to gain 3–4 cm of extra nerve advancement. Direct repair is performed by coapting the ends with either sutures (6/0 to 8/0 Ethilon or Prolene) or by approximating the ends with fibrin glue. A graft (indirect repair) is needed when the gap that exists after resection of the non-functioning neural segment is too large for direct approximation without tension. The length of the graft should be the length of the gap plus 10%. Autograft is usually used, derived from the sural nerve, antebrachial cutaneous nerve, or superficial radial nerve (if not functioning), because these small-caliber grafts achieve better results (faster revascularization) than larger-caliber ones.23 Coaptation of the ends of the graft to the proximal and distal stumps is similar to that used for the direct repair. The introduction of increasingly creative nerve transfers (neurotization) has transformed the surgical arena for brachial plexus injuries, especially in the context of avulsion injury.24,25 Neurotization has changed the outlook for the ‘unrepairable’ avulsion injury to a ‘reconstructable’ one by coapting a proximal functional nerve donor with a distal denervated nerve to reinnervate the latter with healthy donor axons. Reported nerve transfer techniques include neurotization of the spinal accessory to the suprascapular nerve26–29 or radial fascicular to axillary nerve30,31 to achieve shoulder abduction, intercostal32–34 medial pectoral35,36 phrenic37,38 ulnar fascicular nerve transfer to the musculocutaneous nerve,39,40 the double fascicular transfer (ulnar fascicular to musculocutaneous and median fascicular to brachialis)41–43 for elbow flexion (Fig. 18.10), and contralateral C7 spinal nerve for intraplexal repair.43,44 Recovery of the translated function appears to rely on cortical plasticity.46 Fascicle(s) from the functioning ulnar nerve can be transferred to the nerve branches of the biceps and/or brachialis to regain elbow flexion.

252 Hand and Upper Extremity Reconstruction hand is used mainly as a hook. The fingers extend by tenodesis effect, which is produced when the wrist flexes by gravity. In patients with limited hand function, the wrist should not be fused. The loss of tenodesis function from an injudicious wrist fusion procedure will markedly hamper an already limited hand function.

COMPLICATIONS AND SIDE EFFECTS

FIGURE 18.10 Nerve anatomy. Black arrows indicate the lateral cutaneous nerve of the forearm (branch of musculocutaneous nerve). White arrow indicates the branch of the musculocutaneous nerve going to the biceps. Green arrow indicates the branch of the musculocutaneous nerve going to the brachialis. Dotted black indicates ulnar nerve. Dotted white indicates median nerve.

The more widespread use of neurotization to optimize the outcomes from brachial plexus surgery has led to much debate regarding the best choice of nerve transfer technique, and recent literature favors the use of directed discrete transfers to achieve a specific function.25,28 However, one must remember that intraplexal repair (direct or graft), when available, should be performed, with augmentation by extraplexal nerve transfers because of the relatively few extraplexal transfer possibilities available in a severely injured brachial plexus.47 For delayed presentations (longer than 1 year) after brachial plexus injury, nerve reconstruction is not possible because of denervation to the muscles. In these situations, free muscle transfers are the only option to regain elbow flexion and rudimentary finger flexion. In the first operation, a gracilis muscle is used to replace the biceps function. The proximal muscle is anchored to the clavicle and the distal tendon is woven to the biceps tendon. The obturator nerve from the gracilis muscle is coapted to the distal end of the spinal accessory nerve, which is usually functional. The vessels are repaired to the thoracoacromial vessels. This is a highly complex operation that may give a rather gratifying outcome of about 70–90º of elbow motion. Patients usually detect voluntary muscle contraction at 4–6 months after the operation. In a second-stage operation once the patient has attained sufficient elbow flexion, another gracilis muscle is used to power finger flexion. The proximal muscle is attached to the second or third rib and the distal tendons are woven to the flexor tendons in the proximal forearm. The third, fourth and fifth intercostal nerves are used to provide motor nerve input, and the thoracodorsal vessels from the axilla are used for blood flow. The outcome of this second-stage procedure is less satisfying. Patients can attain rather modest finger flexion and the

Complications can occur during brachial plexus operations, but can be minimized by a thorough understanding of not only the nerve anatomy but also the surrounding soft tissue and musculoskeletal anatomy. Russell and Kline’s48 review includes the following categories of injury: neural, vascular, orthopedic, pneumothorax, and wound problems. A common neural injury that occurs during the supraclavicular brachial plexus exploration is to the phrenic nerve. This is particularly vulnerable in its location superficial to the anterior scalene and deep to the sternocleidomastoid. Identification of the nerve and careful mobilization early in the dissection will allow it to be protected during the remainder of the operation. One must avoid inadvertent retraction of the anterior scalene muscle as the neural foramen is approached. Another nerve that is vulnerable because of its superficial anatomy is the spinal accessory nerve. When using a transverse incision, the surgeon should identify the spinal accessory nerve as it travels within the superficial adipose tissue anterior to the trapezius muscle. The nerve should be mobilized and traced proximally towards its emergence from the posterior aspect of the sternocleidomastoid, two-thirds of the way from the sternum to the mastoid process. Use of a nerve stimulator is helpful. During an infraclavicular brachial plexus exploration, the superficial position of the musculocutaneous nerve should be recognized to avoid accidental retraction of the nerve with the surrounding muscle. Placing the arm in the same plane as or lower than the shoulder, the lateral cord/musculocutaneous nerve becomes the most superficial structure under the pectoralis minor. Vascular injury occurs most commonly in the depths of the scalene triangle, usually during exposure of the lower nerve roots. The anterior scalene, as it attaches to the first rib, separates the subclavian vein from the artery. Injury can occur to the parent vessels or to their smaller branches in this region. Small branch injuries are amenable to bipolar coagulation or suture repair; however, significant arterial injury will require an emergent vascular or thoracic consultation. To avoid arterial injury, frequent digital palpation, dissection parallel to the artery, and the addition of an infraclavicular exposure can be useful. Because the brachial plexus is intimate with the subclavian vessels, a nerve injury can be accompanied by a vascular injury. A careful examination of the affected limb, which includes evaluating distal pulses, is crucial, and when necessary, an angiogram may be performed prior to surgery. Postoperative orthopedic issues occur most commonly when the clavicle is divided during brachial plexus exploration. Although visualization of the brachial plexus is easier

Brachial Plexus Reconstructive Techniques 253 with a clavicular osteotomy, postoperative non-union and/ or callus formation can be troublesome. Placing a surgical sponge around the exposed clavicle for retraction should reveal all the necessary anatomy. Pneumothorax can occur with violation of the pleura when dissecting the lower supraclavicular plexus or in harvesting of intercostal nerves. When a pleural injury is noted by bubbling of air during a Valsalva maneuver, it is treated by suture repair of the pleura with or without placing a chest tube. Routine postoperative chest X-rays will identify the presence or absence of a pneumothorax. Wound problems can arise from the accumulation of blood, lymph, or spinal fluid in the wound or pleural cavity after brachial plexus exploration. The thoracic duct traverses the region of dissection over the left side, and if violated, the thoracic duct or its branches must be coagulated. Unnoticed violation of this lymph channel can lead to a lymphocele or chylothorax, which may require re-exploration, chest tube placement, or thoracic duct ligation.

POSTOPERATIVE CARE Documenting recovery after brachial plexus surgery relies on clinical and electrophysiological examinations. Patients should be informed that recovery is a long process, which may last 3–5 years. Preserving range of motion of the joints in the affected extremity is paramount. Physical therapy is recommended for range of motion as well as for maintaining strength in the unaffected muscles. Although recovery from brachial plexus operations has improved with increasingly creative surgical options, a multidisciplinary approach will be required for optimal restoration of function in the injured limb. The treatment of pain by subspecialized anesthesiologists using gabapentin, certain tricyclic antidepressants, or by neurosurgeons employing dorsal root entry zone (DREZ) procedures, can aid in recovery. In addition, reconstructive procedures using free gracilis muscle transfer to regain elbow flexion and some finger motion may be considered for those who are motivated and request these complex options.

CONCLUSION Adult brachial plexus injuries can be devastating, and the long-term implications of such injuries are often not understood by patients or their families. Communication between the patient and the surgeon to manage expectations and to help adapt to unrecoverable functional deficits will optimize outcomes. These injuries are challenging for the managing healthcare practitioner: the treating practitioner must rely upon an understanding of the anatomy, clinical acumen, appropriate use of ancillary radiographic and electrodiagnostic studies to determine the proper course, and timing for offering surgical options. With improved microsurgical techniques, the potential development of pharmacological agents, and the increasingly creative reconstructive options offered by multidisciplinary teams, the outlook for patients suffering severe brachial plexus injures will continue to improve.

REFERENCES 1. Narakas AO. The treatment of brachial plexus injuries. Int Orthop 1985; 9: 29–36. 2. Allieu Y. Evolution of our indications for neurotization. Our concept of functional restoration of the upper limb after brachial plexus injuries. Chir Main 1999; 18: 165–166. 3. Doi K, Muramatsu K, Hattori Y, et al. Restoration of prehension with the double free muscle technique following complete avulsion of the brachial plexus. Indications and long-term results. J Bone Joint Surg [Am] 2000; 82: 652–666. 4. Malone JM, Leal JM, Underwood J, Childers SJ. Brachial plexus injury management through upper extremity amputation with immediate postoperative prostheses. Arch Phys Med Rehab 1982; 63: 89–91. 5. Allieu Y, Cenac P. Is surgical intervention justifiable for total paralysis secondary to multiple avulsion injuries of the brachial plexus? Hand Clin 1988; 4: 609–618. 6. Azze RJ, Mattar J Jr, Ferreira MC, et al. Extraplexual neurotization of brachial plexus. Microsurgery 1994; 15: 28–32. 7. Brandt KE, Mackinnon SE. A technique for maximizing biceps recovery in brachial plexus reconstruction. J Hand Surg [Am] 1993; 18: 726–733. 8. Brunelli G, Monini L. Direct muscular neurotization. J Hand Surg [Am] 1985; 10: 993–997. 9. Doi K, Kuwata N, Muramatsu K, et al. Double muscle transfer for upper extremity reconstruction following complete avulsion of the brachial plexus. Hand Clin 1999; 15: 757–767. 10. Seddon H. Three types of nerve injury. Brain 1943; 66: 237–288. 11. Dubuisson A, Kline DG. Indications for peripheral nerve and brachial plexus surgery. Neurol Clin 1992; 10: 935–951. 12. Aids to the Examination of the Peripheral Nervous System, 4th edn. Edinburgh. Saunders, 2000. 13. Brophy RH, Wolfe SW. Planning brachial plexus surgery. Treatment options and priorities. Hand Clin 2005; 21: 47–54. 14. Shin AY, Spinner RJ, Steinmann SP, Bishop AT. Adult traumatic brachial plexus injuries. J Am Acad Orthop Surg 2005; 13: 382–396. 15. Carvalho GA, Nikkhah G, Matthies C, et al. Diagnosis of root avulsions in traumatic brachial plexus injuries. Value of computerized tomography myelography and magnetic resonance imaging. J Neurosurg 1997; 86: 69–76. 16. Doi K, Otsuka K, Okamoto Y, et al. Cervical nerve root avulsion in brachial plexus injuries. Magnetic resonance imaging classification and comparison with myelography and computerized tomography myelography. J Neurosurg 2002; 96: 277–284. 17. van Ouwerkerk WJ, Strijers RL, Barkhof F, et al. Detection of root avulsion in the dominant C7 obstetric brachial plexus lesion. Experience with three-dimensional constructive interference in steady-state magnetic resonance imaging and electrophysiology. Neurosurgery 2005; 57: 930–940. 18. Walker AT, Chaloupka JC, de Lotbiniere AC, et al. Detection of nerve rootlet avulsion on CT myelography in patients with birth palsy and brachial plexus injury after trauma. AJR Am J Roentgenol 1996; 167: 1283–1287. 19. Kline DG, Happel LT. Penfield Lecture. A quarter century’s experience with intraoperative nerve action potential recording. Can J Neurol Sci 1993; 20: 3–10. 20. Newman M, Nelson N. Digital nerve sensory potentials in lesions of cervical roots and brachial plexus. Can J Neurol Sci 1983; 10: 252–255. 21. Kim DH, Cho YJ, Tiel RL, Kline DG. Outcomes of surgery in 1019 brachial plexus lesions treated at Louisiana State University Health Sciences Center. J Neurosurg 2003; 98: 1005–1016. 22. Spinner RJ, Kline DG. Surgery for peripheral nerve and brachial plexus injuries or other nerve lesions. Muscle Nerve 2000; 23: 680–695. 23. Millesi H. Reappraisal of nerve repair. Surg Clin North Am 1981; 61: 321–340. 24. McGillicuddy JE. Clinical decision making in brachial plexus injuries. Neurosurg Clin North Am 1991; 2: 137–150. 25. Midha R. Nerve transfers for severe brachial plexus injuries – a review. Neurosurg Focus 2004; 16: E5. 26. Hattori Y, Doi K, Fuchigami Y, et al. Experimental study on donor nerves for brachial plexus injury: comparison between the spinal


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accessory nerve and the intercostal nerve. Plast Reconstruct Surg 1997; 100: 900–906. Malessy MJ, de Ruiter GC, de Boer KS, Thomeer RT. Evaluation of suprascapular nerve neurotization after nerve graft or transfer in the treatment of brachial plexus traction lesions. J Neurosurg 2004; 101: 377–389. Merrell GA, Barrie KA, Katz DL, Wolfe SW. Results of nerve transfer techniques for restoration of shoulder and elbow function in the context of a meta-analysis of the English literature. J Hand Surg [Am] 2001; 26: 303–314. Samardzic M, Grujicic D, Antunovic V, Joksimovic M. Reinnervation of avulsed brachial plexus using the spinal accessory nerve. Surg Neurol 1990; 33: 7–11. Kawai H, Akita S. Shoulder muscle reconstruction in the upper type of the brachial plexus injury by partial radial nerve transfer to the axillary nerve. Tech Hand Upper Extrem Surg 2004; 8: 51–55. Witoonchart K, Leechavengvongs S, Uerpairojkit C, et al. Nerve transfer to deltoid muscle using the nerve to the long head of the triceps, part I. an anatomic feasibility study. J Hand Surg [Am] 2003; 28: 628–632. Friedman AH, Nunley JA 2nd, Goldner RD, et al. Nerve transposition for the restoration of elbow flexion following brachial plexus avulsion injuries. J Neurosurg 1990; 72: 59–64. Malessy MJ, Thomeer RT. Evaluation of intercostal to musculocutaneous nerve transfer in reconstructive brachial plexus surgery. J Neurosurg 1998; 88: 266–271. Waikakul S, Wongtragul S, Vanadurongwan V. Restoration of elbow flexion in brachial plexus avulsion injury. Comparing spinal accessory nerve transfer with intercostal nerve transfer. J Hand Surg [Am] 1999; 24: 571–577. Blaauw G, Slooff AC. Transfer of pectoral nerves to the musculocutaneous nerve in obstetric upper brachial plexus palsy. Neurosurgery 2003; 53: 338–341; discussion 341–332. Samardzic M, Grujicic D, Rasulic L, Bacetic D. Transfer of the medial pectoral nerve. myth or reality? Neurosurgery 2002; 50: 1277–1282. Luedemann W, Hamm M, Blomer U, et al. Brachial plexus neurotization with donor phrenic nerves and its effect on pulmonary function. J Neurosurg 2002; 96: 523–526.

38. Songcharoen P. Brachial plexus injury in Thailand: a report of 520 cases. Microsurgery 1995; 16: 35–39. 39. Oberlin C, Ameur NE, Teboul F, et al. Restoration of elbow flexion in brachial plexus injury by transfer of ulnar nerve fascicles to the nerve to the biceps muscle. Tech Hand Upper Extrem Surg 2002; 6: 86–90. 40. Teboul F, Kakkar R, Ameur N, et al. Transfer of fascicles from the ulnar nerve to the nerve to the biceps in the treatment of upper brachial plexus palsy. J Bone Joint Surg [Am] 2004; 86: 1485–1490. 41. Liverneaux PA, Diaz LC, Beaulieu JY, et al. Preliminary results of double nerve transfer to restore elbow flexion in upper type brachial plexus palsies. Plast Reconstruct Surg 2006; 117: 915–919. 42. Mackinnon SE. Preliminary results of double nerve transfer to restore elbow flexion in upper type brachial plexus palsies. Plast Reconstruct Surg 2006; 118: 1273; author reply 1274. 43. Mackinnon SE, Novak CB, Myckatyn TM, Tung TH. Results of reinnervation of the biceps and brachialis muscles with a double fascicular transfer for elbow flexion. J Hand Surg [Am] 2005; 30: 978–985. 44. Gu YD, Cai PQ, Xu F, et al. Clinical application of ipsilateral C7 nerve root transfer for treatment of C5 and C6 avulsion of brachial plexus. Microsurgery 2003; 23: 105–108. 45. Terzis JK, Papakonstantinou KC. The surgical treatment of brachial plexus injuries in adults. Plast Reconstruct Surg 2000; 106: 1097–1122; quiz 1123–1094. 46. Malessy MJ, Thomeer RT, van Dijk JG. Changing central nerve system control following intercostal nerve transfer. J Neurosurg 1998; 89: 568–574. 47. Kline DG, Tiel RL. Direct plexus repair by grafts supplemented by nerve transfers. Hand Clin 2005; 21: 55–69, vi. 48. Russell SM, Kline DG. Complication avoidance in peripheral nerve surgery: preoperative evaluation of nerve injuries and brachial plexus exploration: Part 1. Neurosurgery 2006; 59: 441–448.

CHAPTER

Techniques for Nerve Compression Syndromes

19

David J. Slutsky

INTRODUCTION A neuropathy may be defined as any disorder that results in abnormal nerve function. Neuropathies are frequently associated with a number of systemic disorders, such as diabetes, hypothyroidism, alcoholism, vitamin B12 deficiency, and lead intoxication. The neuropathy may be focal or restricted to a specific anatomical location. Many of these focal neuropathies arise as a result of nerve compression, although traction injuries can play a significant role.

Nerve anatomy and physiology The connective tissue of nerves includes the outer epineurial layer, which contains loosely woven collagen fibers and elastin. The epineurium protects the nerve from compression and stretching and therefore tends to be thicker in places that experience repetitive shear force, such as the cubital tunnel at the elbow. The perineurium separates groups of fascicles and constitutes a diffusion barrier, which protects the axons from infection and chemical insult. The perineurium is relatively unyielding, and this property can lead to a mini-compartment syndrome when the endoneurial pressure increases. The individual axons are surrounded by the endoneurium, which provides support and a framework for regeneration of nerve fibers after injury.

Nerve compression In early nerve compression the symptoms are caused by vascular impairment, and the initial changes occur at the blood–nerve barrier. Fluid shifts that occur with limb position result in endoneurial edema.1 There is no lymphatic drainage of the endoneurial space, and so endoneurial edema clears slowly. The edema cuts off the blood supply by compressing the arterioles that course through the perineurium obliquely.3 This impairs the Na+/K+ exchange

pump that is ATP dependent. This ultimately results in a reversible metabolic conduction block, leading to paresthesia.4 The dramatic relief of symptoms that sometimes occurs after surgical decompression also suggests an ischemic etiology to compression neuropathies. The mechanical source of compression may obstruct venous return, resulting in segmental anoxia, capillary vasodilatation and edema. The edema compounds the compressive effects and leads to abnormal axonal and cellular exchange. Surgical release of compressed nerves at this early stage generally yields good results. Prolonged compression, however, results in intraneural fibrosis, after which nerve recovery is less likely to occur. Nerves are viscoelastic and can change their length in order to accommodate the myriad combination of joint positions. Nerves have a longitudinal blood supply that is reinforced periodically by segmental perforators. They are surrounded by a vascularized gliding layer to facilitate the nerve gliding that accompanies joint movement. Chronic compression leads to inflammation and secondary fibrosis to disrupt this gliding layer, ultimately leading to nerve tethering. Any compressive neuropathy therefore frequently has a component of traction neuropathy as well. Traction alone can cause conduction block. Nerves can only elongate by 8% until there is a disruption of the blood supply.5 Traction therefore leads to nerve ischemia with secondary impairment of the Na+/K+ pump to cause a conduction block. This is clinically manifested as numbness or paresthesia. Many of the provocative tests for nerve compression induce relative nerve ischemia in the already susceptible nerves through manual pressure, awkward joint positioning and/or traction to elicit numbness or paresthesia in the distribution of that specific nerve. A knowledge of the normal nerve course and topographic anatomy is thus essential.

255


ELECTRODIAGNOSTIC STUDIES Ancillary testing cannot replace a detailed history and thorough examination of the upper limb, but it can provide a means for staging the degree of neuropathy and ruling out more generalized disorders that may masquerade as a focal neuropathy. Nerve fibers show varying susceptibility to compression.6 The large fibers are more vulnerable to compression and ischemia. The neurophysiology of electrical recording is such that the recording electrode will detect activity in the largest myelinated fibers first, because these fibers conduct at the fastest rates and have a lower depolarization threshold than the small unmyelinated nerves. Latency and conduction velocity depend on the time that elapses from stimulation of the nerve to the first recording. If only a fraction of the large thick myelinated fibers remain and transmit impulses, the recorded latency and conduction velocity remain normal because the recording electrode mostly detects the fastest fibers.7 The electrical conduction in smaller, less myelinated or non-myelinated nerves is much slower, and hence not usually detected in a routine nerve conduction study (NCS). Large myelinated and small unmyelinated fibers can be affected differently. Connective tissue changes follow after focal nerve fiber changes. The large myelinated nerves undergo segmental demyelination, whereas the small unmyelinated nerves undergo degeneration and regeneration. Normal fascicles are adjacent to abnormal fascicles. The nerve conduction study only tests the faster-conducting fibers. This explains the seeming paradox of the patient who has established carpal tunnel syndrome but yet normal electrodiagnostic studies. It is the worst fascicles that produce symptoms, but it is the best fascicles that account for the normal nerve conduction studies.8 With early compression the symptoms are intermittent, and the edema is reversible. When there are constant symptoms, there is usually myelin damage and/or chronic endoneurial edema. This demyelination is responsible for the slowing of nerve conduction. If the compression continues, some of the axons will die. If there are fewer nerve fibers, the size of the electrical charge will be smaller, leading to smaller amplitudes. When there is sensory or motor loss, there is usually degeneration of nerve fibers. Despite the restoration of neural blood flow following nerve decompression, remyelination of the axon is often incomplete, which accounts for persistently abnormal nerve conduction even though the patient may be without symptoms.9

Quantitative sensory testing (QST) Quantitative sensory testing is reportedly more sensitive than the NCS because only 25% of the large myelinated nerve fibers need to be conducting normally in order to yield a normal nerve conduction test. Nerve density is defined as the number of nerve fibers per mm2. The nerve threshold is the minimum amount of force necessary to cause the touch receptors to fire. With nerve degeneration it is more difficult to distinguish two points from one point. Static

and moving two-point discrimination typically tests the density of innervation. Threshold tests would include vibrometry and Semmes–Weinstein monofilament testing (SWT). Vibrometry is relatively insensitive to early changes and is not commonly used. Semmes–Weinstein testing involves placing nylon filaments of varying thickness on the skin until the patient can detect the touch of specific filament thickness. The test is repeated with varying diameter filaments until the threshold is determined. Abnormal SWT is consistent with nerve demyelination.

MEDIAN NEUROPATHIES DISTAL MEDIAN NEUROPATHY Carpal tunnel syndrome Anatomy

The carpal tunnel is open-ended proximally and distally, but behaves like a closed compartment physiologically and maintains its own distinct tissue fluid pressure levels. It is a fibro-osseous canal that is bound by the concave arch of the carpal bones dorsally and the flexor retinaculum palmarly. The hook of the hamate, triquetrum, and pisiform form the ulnar border; the radial border consists of the scaphoid, trapezium, and the fascial septum overlying the FCR. The flexor retinaculum consists of three zones: a proximal zone that is continuous with the deep forearm fascia, a central zone that is composed of the transverse carpal ligament (TCL), and a third zone that consists of the aponeurosis between the thenar and hypothenar muscles.13 The median nerve at the wrist has approximately 30 fascicles. The motor recurrent branch often consists of two fascicles that are situated in a volar position, with the various sensory groups in the radial, ulnar and dorsal positions of the main trunk. The motor branch can be separated from the main trunk without harm for up to 100 mm proximal to the thenar muscles.14 The sensory fibers travel within the common digital nerves to the thumb, index and middle fingers, as well as the communicating branch to the third web space.

Pathophysiology There are two potential sites of compression anatomically. The first is at the proximal edge of the TCL, where compression may be produced by acute wrist flexion. This accounts for the positive Phalen’s test (wrist flexion test) in CTS. The second is adjacent to the hook of the hamate where an hourglass deformity of the median nerve may be seen. Patients with compression in this area will have a positive median nerve compression (Durkan’s) test but a negative Phalen’s test.15 Compression within the carpal tunnel may also result from any lesion that takes up space within the canal, such as flexor tenosynovitis, hematoma, palmar carpal dislocation, distal radius fractures, tumors and ganglia. Although many cases have been attributed to a non-specific synovitis, synovial biopsies typically fail to

Techniques for Nerve Compression Syndromes 257 show evidence of inflammation. They do reveal edema and vascular sclerosis, which may be secondary to compression rather than the primary event.

History The patient typically complains of numbness and paresthesia in the median nerve distribution. Initially the symptoms occur at night, owing to a combination of wrist flexion during sleep and fluid shifts that occur with the horizontal position, which increases the carpal canal pressure. In this early stage of nerve compression, the symptoms are of a vascular nature, which culminate in endoneurial edema. With early compression the symptoms are intermittent and the edema is reversible. As the symptoms progress, they become more frequent during the day and are precipitated by gripping and pinching activities as well as those tasks requiring repetitive wrist flexion. When there are constant symptoms, there is usually myelin damage and/or chronic endoneurial edema.16

Non-operative management Non-operative therapy includes splinting the wrist in a neutral position, steroid injections, and management of any underlying systemic diseases. Steroid injection offers transient relief to 80% of patients, but only 20% will be symptom free 12 months later. Those most likely to benefit from conservative management have had symptoms for less than 1 year, only intermittent numbness, normal two-point discrimination, 120% drop in amplitude. When this is combined with FDI conduction and interosseous-latency differences, the diagnostic yield increases.

Quantitative sensory testing The 2PS to the small finger is the first to go, followed by an abnormal 1PS. The dorsoulnar wrist should remain normal unless there is an associated C8–T1 radiculopathy.

Non-operative treatment The mainstay of treatment is activity modification. Cyclists should avoid riding in the crouching position with their hands low on the handlebars because this is a recognized precipitant of symptoms; they should change their hand position frequently. Autobody repair technicians, martial artists and Kodo drummers should avoid repetitive percussion on the ulnar border of their palm. Wrist splinting and cortisone injections have no role in this condition.

Indications for surgery Intrinsic muscle wasting and/or sensory loss are a sine qua non for decompression. The presence of a mass occupying lesion also mandates surgical treatment. Ulnar artery thrombosis or aneurysm may be treated with ulnar artery repair or ligation.

Contraindications Ulnar motor and/or sensory disturbances due to more proximal causes preclude a distal release. Ulnar sensory disturbances in CTS were a common indication for release in the 1980s, but have since become an infrequent indication for the release of Guyon’s canal because the majority of patients experience improvement following CTR.23

Surgical technique The ulnar nerve is identified proximal to the distal wrist crease between the FCU and the flexor tendons through a curving incision that crosses the wrist obliquely and bisects the interval between the pisiform and the hook of the hamate. The ulnar nerve is followed distally as the volar carpal ligament is released. The ulnar artery is inspected for thrombosis or aneurysm. The fibrous arch of the hypothenar muscles is incised and the floor of the canal is explored for masses, fibrous bands or anomalous muscles. With entrapment in the palm, the deep motor branch is followed distally as it traverses the palm lying on the interosseous fascia, deep to the flexor tendons and superficial palmar arch. The dissection is completed as the motor branch ends in the muscle belly of the adductor pollicis (Fig. 19.7A–D).

Complications These are mostly related to injury to the branches of the ulnar nerve or artery. Injury to the palmar cutaneous branches of the ulnar nerve or the nerve of Henle (if present)


A B FIGURE 19.7 Distal ulnar neuropathy. A Dorsal preoperative photograph of attempted index finger abduction. Note the marked wasting of the first, second and third dorsal interossei. B Volar preoperative photograph of attempted index finger abduction. Note the marked wasting of the first, second and third dorsal interossei, but the normal bulk of the abductor digiti minimi (arrows).

may result in scar tenderness and hypoesthesia. Uncommonly injury to the pisiform ligament complex can result in instability of the pisotriquetral joint.65

Outcomes Clinical recovery is seen in the majority of patients when the ulnar nerve entrapment is due to a space-occupying lesion.66 Motor recovery is less predictable than sensory recovery, especially when the compression is due to a fibrotic hypothenar arch or is long-standing.67

RADIAL NEUROPATHIES Upper arm

nerve is regularly crossed by several prominent veins, the ‘leash of Henry.’ It divides 2 cm distal to the elbow into a superficial radial sensory branch (SRN) and a deep motor branch, the posterior interosseous nerve (PIN). Before giving off the PIN branch it gives off branches to the extensor carpi radialis longus and brevis, brachioradialis and anconeus. The PIN continues on between the superficial and deep head of the supinator muscle, to exit on the dorsal forearm. After it emerges from the distal border of the supinator, the PIN sends branches, in descending order, to the extensor digitorum communis, extensor carpi ulnaris, extensor digiti quinti, extensor pollicis longus and brevis and the extensor indicis proprius, although there may be considerable variation.

Anatomy

History

The radial nerve arises from the posterior cord of the brachial plexus and receives contributions from C5–C8 spinal roots. The nerve contains approximately 16 000 myelinated fibers.12 At the level of the coracobrachialis it courses posteriorly to lie in the spiral groove of the humerus. In the lower arm it pierces the lateral intermuscular septum to run between the brachialis and the brachioradialis. Opposite the head of the radius there are some fibrous bands from the joint’s capsule, and immediately distal to this the

In the arm region the radial nerve is often injured in association with some form of unconsciousness. In a ‘Saturday night palsy’ an obtunded patient sits with the arm over a chair back or rests his/her head on the lateral surface of the arm. Alternatively, the radial nerve can be compressed in the groove between the brachialis and forearm muscles when one person rests their head on the middle third of the arm of another, for example in ‘Honeymooner’s palsy.’

Techniques for Nerve Compression Syndromes 271

C

D

FIGURE 19.7, cont’d C Intraoperative view following an ulnar nerve decompression in Guyon’s canal as it splits into a superficial sensory branch (white asterisk) and deep motor branch (*) which passes under the hypothenar arch. D Six months after operation. Note the normal bulk of the dorsal interossei and the active index finger abduction. (From Slutsky DJ. Electrodiagnostic studies of the upper extremity. In: Slutsky DJ, Hentz VR, eds. Peripheral nerve surgery: practical applications in the upper extremity. Philadelphia: Elsevier, 2006, with permission.)

Physical examination The patient will typically present with a wrist drop and an inability to extend the fingers, thumb or wrist. In addition, the brachioradialis will be affected along with variable involvement of the triceps. There will also be diminished sensation over the dorsum of the first web space. The NCS typically demonstrates the absence of the superficial radial SNAP. Motor recordings are more difficult because no muscle is sufficiently isolated from other radially innervated muscles.

Indications for surgery For the majority of patients, non-operative treatment is the mainstay. Failure to improve within 6 months, combined with a non-advancing Tinel’s sign, is an indication for exploration.

Contraindications The time for reinnervation must take the distance from the injury to the motor endplate into account. As a general rule,

motor endplates degrade at about 1% per week, and the nerve regenerates about 1 inch per month. By 12 months, the nerve will have grown approximately 12 inches and there will be a 50% loss of endplates, hence the maximum length that a nerve can grow to restore motor function is approximately 13–18 inches. For practical purposes, nerve decompression will be of no value with injuries that are more than 18 months old (>75% loss of endplates) and alternative methods should be explored.

Surgical technique A 6–8 cm incision is made over the posterolateral aspect of the midhumerus. The radial nerve is identified in the spiral groove and followed distally through the intermuscular septum. Any obvious areas of nerve constriction or loss of the normal striations (bands of Fontana) should undergo epineurolysis. The use of intraoperative nerve stimulation will help differentiate a neuroma-in-continuity from nonviable nerve tissue. In the former case an internal neurolysis is justified rather than excision and grafting.

272 Hand and Upper Extremity Reconstruction Postoperative management

Contraindications

Immediate elbow mobilization is instituted following nerve decompression or neurolysis. Nerve grafting may require temporary elbow splinting for 4 weeks, but it is preferable to insert a graft of sufficient length to allow early elbow extension.

The existence of this disorder is still questioned by some authors. All efforts should be made to rule out other causes of pain, such as radiocapitellar joint disorders, lateral elbow instability, and untreated lateral epicondylitis.

Complications

The volar approach to the radial nerve is through an 8-cm anterolateral incision under tourniquet control. The muscular fascia is divided and the intermuscular interval between the brachialis and brachioradialis is developed with blunt dissection. Recurrent branches from the radial artery must be ligated to gain access to both nerve branches. The radial nerve is identified proximal to the elbow and followed distally. At the level of the radial head, the radial nerve gives off branches to the ECRB and brachioradialis. It then divides into the superficial radial nerve branch, which travels distally under the brachioradialis. The PIN continues distally and is crossed by the radial recurrent vessels, which are ligated. The proximal border of the supinator muscle (the arcade of Frohse) is divided along with the superficial head of the supinator (Fig. 19.8A,B). At this point the PIN disappears from view as it penetrates the dorsal extensor compartment. If there is a suspicion of distal entrapment, a separate dorsal approach to the PIN is necessary. This can be accomplished by extending the incision distally and dorsally, or by making a separate incision. The PIN is then approached through a dorsolateral approach, developing the plane between the extensor carpi radialis brevis and the extensor digitorum communis (Fig. 19.9A–D). At this level, the PIN contains motor fibers only, hence separate fascicle identification is unnecessary. The distal border of the supinator is delineated and divided

The radial nerve is accompanied by the radial collateral artery in the spiral groove, which is at risk during decompression. Injury to the muscular branches may result in permanent denervation of one or more heads of the triceps. Injury to the posterior cutaneous nerve of the forearm may result in a tender scar and hypoesthesia.

Radial tunnel syndrome History

The presenting complaint in radial tunnel syndrome is proximal forearm pain, often coexisting with lateral epicondylitis, without sensory or motor loss. The patient often gives a history of performing repetitive pronation/supination activities, such as using a screwdriver. The symptoms of radial tunnel syndrome often coexist with and overlap those of lateral epicondylitis.

Physical examination A number of provocative tests have been described, including resisted extension of the middle finger, which tenses the ECRB and entraps the nerve, tenderness over the supinator muscle, and pain with resisted supination. None is pathognomonic for this condition.69 A diagnostic local anesthetic block of the PIN, which produces a temporary wrist drop, is useful in confirming the diagnosis if the pain is completely relieved. Classically the NCS is normal in radial tunnel syndrome.

Non-operative management The majority of cases will resolve with modification of activity. In the early stages above-elbow splinting with the elbow flexed to 90º and the forearm in supination will relieve the dynamic compression and allow the inflammatory response around the PIN to subside. PIN gliding exercises will help maintain nerve excursion: these consist of simultaneous elbow extension, forearm pronation, wrist flexion and ulnar deviation. In many instances the treatment that is instituted for a coexisting lateral epicondylitis will also resolve the symptoms of radial tunnel compression.

Indications for surgery Persistent proximal forearm pain that does not resolve despite appropriate activity modification is an indication for decompression, especially if a lateral epicondylectomy has already been performed. Complete pain relief following a diagnostic PIN block is a good predictor of at least partial improvement following surgery.

Surgical technique

Outcomes Early reports of radial tunnel decompression were generally optimistic. Beasley et al.71 reported 80% good or excellent results in his series of 109 decompressions. A recent review by Sotereanos et al.,72 however, found good results in only 11 of 28 patients, with many experiencing residual symptoms. The results were worse in patients receiving worker’s compensation.

Complications The potential complications are similar for radial tunnel syndrome and PIN decompression. The main indication to ligate the radial leash of vessels is to prevent postoperative bleeding, because they are a rare cause of compression by themselves. The superficial radial nerve is at risk of injury through laceration or retraction. Persistent radial tunnel syndrome due to unrelieved PIN compression at the distal border of the supinator may require repeat surgery.

Posterior interosseous nerve entrapment History

In posterior interosseous nerve syndrome the presenting symptoms are weakness and/or paralysis of the extensor

Techniques for Nerve Compression Syndromes 273

A B FIGURE 19.8 Anterolateral approach to PIN decompression. A Anterior approach with a view of the proximal volar forearm demonstrating the arcade of Struthers(*). SRN = superficial radial nerve. PIN = posterior interosseous nerve. B After release of the arcade. Note the normal appearance of the PIN. RN = radial nerve. (From Slutsky DJ. Electrodiagnostic studies of the upper extremity. In: Slutsky DJ, Hentz VR, eds. Peripheral nerve surgery: practical applications in the upper extremity. Philadelphia: Elsevier, 2006, with permission.)

muscles, which results in a wrist or finger drop. There may be a history of a fall onto an extended and pronated arm, although many cases are spontaneous, especially if due to an underlying lipoma, ganglion or rheumatoid nodule arising from the radiocapitellar joint.

Physical examination The patient will present with variable weakness or paralysis of the EPL, EIP, EDC and ECU. Motor function of the ECRB/L should be preserved because they are innervated before the PIN dives between the two heads of the supinator muscle. The patient will therefore extend their wrist in radial deviation. PIN lesions do not affect the superficial radial SNAP, which should be normal. The compound motor action potential of PIN-innervated muscles may show a drop in conduction velocity or amplitude, but this is difficult to assess with surface electrodes. Needle EMG is the best technique for localization, especially with partial lesions.19 The management of this syndrome is identical to that for radial tunnel syndrome.

Superficial radial nerve entrapment

bifurcates into a major volar and a major dorsal branch at a mean distance of 4.2 cm proximal to the radial styloid. It then moves distally, where it supplies sensation to the dorsum of the thumb, the first web space and the dorsoradial aspect of the carpus, extending up to the index and middle fingers.

Pathophysiology The superficial radial nerve (SRN) can be injured in the distal forearm or at the wrist by tight bracelets or watch bands, handcuffs, radius fractures, lacerations, venous cutdown and blunt trauma. The SRN may also be entrapped as it exits the fascia between the tendons of the BR and ECRB.

History Pertinent history may include compressive or crushing forearm injuries, work activities requiring frequent pronation and wrist hyperextension, and associated illnesses, such as diabetes. Symptoms included altered sensibility over the dorsoradial aspect of the hand, and dorsoradial cutaneous pain with ulnar flexion of the wrist or with gripping and pinching.

Anatomy

Physical examination

The radial sensory nerve exits from under the brachioradialis approximately 5 cm proximal to the radial styloid, and

Physical examination includes altered touch perception, moving 2PD >15 mm, static 2PD that is 5 mm greater than


A

B

D

C FIGURE 19.9 Combined anterior and posterolateral approach to P.I.N. decompression. A Skin incision for combined approach. B Exposure of the PIN (*) between the extensor carpi radialis brevis and the extensor digitorum communis. C Dissection of the superficial radial nerve (SRN) showing its relation to the PIN. Note the radial leash of vessels (*). D After skin closure.

at the contralateral first web space, a positive Tinel’s sign over the SRN, and aggravation of the patient’s symptoms with forced forearm pronation and wrist ulnar flexion.74

Quantitative sensory testing The patients will have an abnormal 2PS and possibly 1PS over the dorsum of the first web.

Electrodiagnostic studies The distal radial sensory latency may be normal even in the presence of abnormal forearm conduction. This commonly occurs with nerve entrapment due to segmental conduction velocity slowing. In more advanced cases slowing or a complete block of the distal SRN occurs. If the response is absent, it is difficult to localize the lesion.

Indications for surgery Failure to improve following conservative treatment, with avoidance of repetitive wrist deviation and tight bands or jewelry, is an appropriate reason.

Contraindications De Quervain’s tenosynovitis often includes a component of superficial radial nerve irritation and should be treated before considering SRN decompression.

Surgical technique A 2 cm incision is made approximately proximal to the radial styloid. The superficial radial nerve is identified as it exits from underneath the tendon of the brachioradialis. The overlying fascia is split, care being taken not to disturb the nerve.

Outcomes

Dellon and MacKinnon74 reported on a group of 51 patients with complaints related to entrapment of the superficial sensory branch of the radial nerve. Seven (37%) of 19 patients treated with non-operative modalities were improved after a mean of 28 months from the onset of symptoms or their injury. Of the 32 patients treated with surgery, there was excellent subjective improvement in

Techniques for Nerve Compression Syndromes 275 37%, good subjective improvement in 49%, and fair subjective improvement in 6%; 8% were not improved.74

Complications The complications for each procedure are similar. They include wound problems related to infection, skin healing, tender scars due to injured cutaneous nerves, hematoma and iatrogenic injury due to rough nerve handling and/or retraction. These can be minimized by meticulous hemostasis, gentle nerve handling, and precise surgical technique. Stiffness can occur and is minimized by early joint mobilization. The incidence of residual symptoms is predicated by the preoperative degree of nerve injury.

CONCLUSIONS It is apparent that compressive neuropathies share similar features. Although each focal neuropathy has been discussed in isolation, multiple compressive neuropathies often coexist. The element common to all focal neuropathies is nerve ischemia, which leads to the sensory and/or motor abnormalities in the distribution of the specific nerve that is affected. Provocative tests exploit this feature by seeking to dynamically increase the ischemia through external pressure and/or traction in order to magnify the symptoms. Although ancillary testing can yield useful information, most hand surgeons intuitively understand that the indication for surgery still hinges on reproducible physical findings combined with the appropriate clinical symptoms rather than on a test abnormality.

REFERENCES 1. Rydevik B, Lundborg G. Permeability of intraneural microvessels and perineurium following acute, graded experimental nerve compression. Scand J Plast Reconstruct Surg 1977; 11: 179–187. 2. Lundborg G. Ischemic nerve injury. Experimental studies on intraneural microvascular pathophysiology and nerve function in a limb subjected to temporary circulatory arrest. Scand J Plast Reconstruct Surg 1970; 6: 3–113. 3. Lundborg G, Dahlin LB. The pathophysiology of nerve compression. Hand Clin 1992; 8: 215–227. 4. Clark WL, Trumble TE, Swiontkowski MF, Tencer AF. Nerve tension and blood flow in a rat model of immediate and delayed repairs. J Hand Surg [Am] 1992; 17: 677–687. 5. Dahlin LB, Shyu BC, Danielsen N, Andersson SA. Effects of nerve compression or ischaemia on conduction properties of myelinated and non-myelinated nerve fibres. An experimental study in the rabbit common peroneal nerve. Acta Physiol Scand 1989; 136: 97–105. 6. Brumback RA, Bobele GB, Rayan GM. Electrodiagnosis of compressive nerve lesions. Hand Clin 1992; 8: 241–254. 7. Dellon AL. Pitfalls in interpretation of electrophysiological testing. In: Gelberman RHR, ed. Operative nerve repair and reconstruction. Philadelphia: JB Lippincott, 1991; 185–196. 8. Eversmann WW Jr, Ritsick JA. Intraoperative changes in motor nerve conduction latency in carpal tunnel syndrome. J Hand Surg [Am] 1978; 3: 77–81. 9. Trojaborg W, Sindrup EH. Motor and sensory conduction in different segments of the radial nerve in normal subjects. J Neurol Neurosurg Psychiatry 1969; 32: 354–359. 10. Cobb TK, Dalley BK, Posteraro RH, Lewis RC. Anatomy of the flexor retinaculum. J Hand Surg [Am] 1993; 18: 91–99.

11. Williams HB, Jabaley ME. The importance of internal anatomy of the peripheral nerves to nerve repair in the forearm and hand. Hand Clin 1986; 2: 689–707. 12. Szabo RM, Slater RR Jr, Farver TB, et al. The value of diagnostic testing in carpal tunnel syndrome. J Hand Surg [Am] 1999; 24: 704–714. 13. Mackinnon SE, Dellon AL. Experimental study of chronic nerve compression. Clinical implications. Hand Clin 1986; 2: 639–650. 14. Lundborg G, Gelberman RH, Minteer-Convery M, et al. Median nerve compression in the carpal tunnel–functional response to experimentally induced controlled pressure. J Hand Surg [Am] 1982; 7: 252–259. 15. Bennett JB, Crouch CC. Compression syndrome of the recurrent motor branch of the median nerve. J Hand Surg [Am] 1982; 7: 407–409. 16. Dumitru D. Electrodiagnostic medicine. In: Dumitru D, ed. Electrodiagnostic medicine. Philadelphia: Hanley and Belfus, Inc., 1995; 47–584. 17. Gelberman RH, Aronson D, Weisman MH. Carpal-tunnel syndrome. Results of a prospective trial of steroid injection and splinting. J Bone Joint Surg [Am] 1980; 62: 1181–1184. 18. Gelberman RH, Pfeffer GB, Galbraith RT, et al. Results of treatment of severe carpal-tunnel syndrome without internal neurolysis of the median nerve. J Bone Joint Surg [Am] 1987; 69: 896–903. 19. Silver MA, Gelberman RH, Gellman H, Rhoades CE. Carpal tunnel syndrome: associated abnormalities in ulnar nerve function and the effect of carpal tunnel release on these abnormalities. J Hand Surg [Am] 1985; 10: 710–713. 20. Shum C, Parisien M, Strauch RJ, Rosenwasser MP. The role of flexor tenosynovectomy in the operative treatment of carpal tunnel syndrome. J Bone Joint Surg [Am] 2002; 84A: 221–225. 21. Weber RA, Rude MJ. Clinical outcomes of carpal tunnel release in patients 65 and older. J Hand Surg [Am] 2005; 30: 75–80. 22. Boyd KU, Gan BS, Ross DC, et al. Outcomes in carpal tunnel syndrome: symptom severity, conservative management and progression to surgery. Clin Invest Med 2005; 28: 254–260. 23. Slutsky D. Agee endoscopic carpal tunnel release. In: Slutsky DJ, Nagel D, ed. Techniques in hand and wrist arthroscopy. Philadelphia: Elsevier, 2007; 242–248. 24. Murphy RX Jr, Jennings JF, Wukich DK. Major neurovascular complications of endoscopic carpal tunnel release. J Hand Surg [Am] 1994; 19: 114–118. 25. Luallin SR, Toby EB. Incidental Guyon’s canal release during attempted endoscopic carpal tunnel release: an anatomical study and report of two cases. Arthroscopy 1993; 9: 382–386; discussion 381. 26. Varitimidis SE, Herndon JH, Sotereanos DG. Failed endoscopic carpal tunnel release. Operative findings and results of open revision surgery. J Hand Surg [Br] 1999; 24: 465–467. 27. Agee JM, McCarroll HR Jr, Tortosa RD, et al. Endoscopic release of the carpal tunnel: a randomized prospective multicenter study. J Hand Surg [Am] 1992; 17: 987–995. 28. Trumble TE, Diao E, Abrams RA, Gilbert-Anderson MM. Singleportal endoscopic carpal tunnel release compared with open release: a prospective, randomized trial. J Bone Joint Surg [Am] 2002; 84A: 1107–1115. 29. Schonauer F, Varma S, Belcher HJ. Endoscopic carpal tunnel release: practice in evolution. Scand J Plast Reconstruct Surg Hand Surg 2003; 37: 360–364. 30. Zhao X, Lao J, Hung LK, et al. Selective neurotization of the median nerve in the arm to treat brachial plexus palsy. An anatomic study and case report. J Bone Joint Surg [Am] 2004; 86A: 736–742. 31. Nigst H, Dick W. Syndromes of compression of the median nerve in the proximal forearm (pronator teres syndrome; anterior interosseous nerve syndrome). Arch Orthop Trauma Surg 1979; 93: 307–312. 32. Wertsch JJ, Melvin J. Median nerve anatomy and entrapment syndromes: a review. Arch Phys Med Rehab 1982; 63: 623–627. 33. Olehnik WK, Manske PR, Szerzinski J. Median nerve compression in the proximal forearm. J Hand Surg [Am] 1994; 19: 121–126. 34. Szabo RM, Koo JT. Compression neuropathies of the median nerve. In: Slutsky DJ, ed. Peripheral nerve surgery: practical


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applications in the upper extremity. Philadelphia: Elsevier 2006; 219–242. Werner CO, Rosen I, Thorngren KG. Clinical and neurophysiologic characteristics of the pronator syndrome. Clin Orthop 1985; 231–236. Hartz CR, Linscheid RL, Gramse RR, Daube JR. The pronator teres syndrome: compressive neuropathy of the median nerve. J Bone Joint Surg [Am] 1981; 63: 885–890. Johnson RK, Spinner M, Shrewsbury MM. Median nerve entrapment syndrome in the proximal forearm. J Hand Surg [Am] 1979; 4: 48–51. Wong L, Dellon AL. Brachial neuritis presenting as anterior interosseous nerve compression – implications for diagnosis and treatment: a case report. J Hand Surg [Am] 1997; 22: 536–539. Srinivasan R, Rhodes J. The median-ulnar anastomosis (MartinGruber) in normal and congenitally abnormal fetuses. Arch Neurol 1981; 38: 418–419. Mysiew WJ, Coalchis SC. Electrophysiologic study of the anterior interosseous nerve. Am J Phys Med Rehab 1988: 50–54. Nagano A, Shibata K, Tokimura H, et al. Spontaneous anterior interosseous nerve palsy with hourglass-like fascicular constriction within the main trunk of the median nerve. J Hand Surg [Am] 1996; 21: 266–270. von Schroeder HP, Scheker LR. Redefining the ‘Arcade of Struthers.’ J Hand Surg [Am] 2003; 28: 1018–1021. Wehrli L, Oberlin C. The internal brachial ligament versus the arcade of Struthers: an anatomical study. Plast Reconstruct Surg 2005; 115: 471–477. De Jesus R, Dellon AL. Historic origin of the ‘Arcade of Struthers.’ J Hand Surg [Am] 2003; 28: 528–531. Bartels RH, Grotenhuis JA, Kauer JM. The arcade of Struthers: an anatomical study. Acta Neurochir (Wien) 2003; 145: 295–300; discussion 300. Siqueira MG, Martins RS. The controversial arcade of Struthers. Surg Neurol 2005; 64: 17–20; discussion: 20–21. Posner MA. Compressive ulnar neuropathies at the elbow: I. Etiology and diagnosis. J Am Acad Orthop Surg 1998; 6: 282–288. Spinner M, Spencer PS. Nerve compression lesions of the upper extremity. A clinical and experimental review. Clin Orthop 1974; 0: 46–67.

49. Campbell WW, Pridgeon RM, Riaz G, et al. Sparing of the flexor carpi ulnaris in ulnar neuropathy at the elbow. Muscle Nerve 1989; 12: 965–967. 50. Novak CB, Lee GW, Mackinnon SE, Lay L. Provocative testing for cubital tunnel syndrome. J Hand Surg [Am] 1994; 19: 817–820. 51. Tomaino MM, Brach PJ, Vansickle DP. The rationale for and efficacy of surgical intervention for electrodiagnostic-negative cubital tunnel syndrome. J Hand Surg [Am] 2001; 26: 1077–1081. 52. Kim DH, Han K, Tiel RL, et al. Surgical outcomes of 654 ulnar nerve lesions. J Neurosurg 2003; 98: 993–1004. 53. Shea JD, McClain EJ. Ulnar-nerve compression syndromes at and below the wrist. J Bone Joint Surg [Am] 1969; 51: 1095–1103. 54. Wu JS, Morris JD, Hogan GR. Ulnar neuropathy at the wrist: case report and review of literature. Arch Phys Med Rehab 1985; 66: 785–788. 55. McIntosh KA, Preston DC, Logigian EL. Short-segment incremental studies to localize ulnar nerve entrapment at the wrist. Neurology 1998; 50: 303–306. 56. Rayan GM, Jameson BH, Chung KW. The pisotriquetral joint: anatomic, biomechanical, and radiographic analysis. J Hand Surg [Am] 2005; 30: 596–602. 57. Foucher G, Berard V, Snider G, et al. Distal ulnar nerve entrapment due to tumors of Guyon’s canal. A series of ten cases. Handchir Mikrochir Plast Chir 1993; 25: 61–65. 58. Zoch G, Meissl G, Millesi H. [Results of decompression of the ulnar nerve in Guyon’s canal]. Handchir Mikrochir Plast Chir 1990; 22: 125–129. 59. Eaton CJ, Lister GD. Radial nerve compression. Hand Clin 1992; 8: 345–357. 60. Rinker B, Effron CR, Beasley RW. Proximal radial compression neuropathy. Ann Plast Surg 2004; 52: 174–180; discussion 81–83. 61. Sotereanos DG, Varitimidis SE, Giannakopoulos PN, Westkaemper JG. Results of surgical treatment for radial tunnel syndrome. J Hand Surg [Am] 1999; 24: 566–570. 62. Dellon AL, Mackinnon SE. Radial sensory nerve entrapment in the forearm. J Hand Surg [Am] 1986; 11: 199–205.

CHAPTER

Thumb Reconstruction

20

Sang-Hyun Woo

The importance of thumb reconstruction cannot be overemphasized, as 40–50% of total hand function is performed by the thumb. Replantation of the thumb is mandatory, irrespective of the level of amputation, because successful replantation both maximizes patient satisfaction and minimizes donor-site morbidity from subsequent reconstructive efforts. When replantation is not a viable option, this chapter will provide the surgeon with a number of options for thumb reconstruction, based on the type and extent of the tissue defect. The objective of thumb reconstruction is to restore mobility, stability, pain-free sensibility, sufficient length to provide opposition, and good appearance. In children, growth potential must also be considered. Although there are a number of very successful reconstructive procedures, and new procedures are continually being developed, the surgeon must always take into consideration the informed decision of the patient over and above their own preference.

PULP DEFECT The pulp area of the thumb is characterized by its high concentration of sensory nerve endings. The pulp has therefore been referred to as a ‘third eye.’ Also, because of the numerous septa between the distal phalangeal bone and the skin, the pulp works to prevent slippage when pinching objects. In reconstruction, the original pulp thickness and color should be well matched and the result of the reconstruction should be stable and durable. Adequate thickness with excellent two-point discrimination in the pulp is essential, and there ought to be no shearing between the bone and the skin. There are various options for reconstruction based on the size and shape of the defect, as well as the surgeon’s preference. First, the size of the defect can be classified as small, medium, large or very large (Fig. 20.1). A small defect is half the length of the nail. In cases where there is no

exposure of the distal phalangeal bone, such defects can heal spontaneously with conservative management, such as occlusive or semiocclusive dressings, especially in children. Another option is a simple volar V-Y advancement flap, although this procedure sometimes results in cold intolerance and a hook-nail deformity. A medium defect is one confined to the area extending proximally to the halfway point of the nail, but limited to the level of the nail fold. This defect can be covered by a cross-finger or cross-side finger flap. In addition, a palmar advancement flap1 or extended palmar advancement flap2 can be used, as well as the modification of this procedure that encompasses the complete mobilization of all proximal palmar soft tissue, as demonstrated by Hueston3 and Argamaso4 (Fig. 20.2). In cases where there is a large defect that extends proximally to the nail fold at the interphalangeal crease, a palmar advancement flap is not ideal because it often causes an interphalangeal joint contracture.5 For a large defect, the surgeon may opt to employ a dorsolateral island flap,6 a dorsoulnar reversed island flap,7 a neurovascular island flap, or Littler’s flap8 from the non-critical side of the middle or ring finger. However, the neurovascular island flap presents some disadvantages with regard to cortical reorientation problems and scarring of the donor finger.9 Another sensate flap is the dorsal island or kite flap,10 in spite of the differences in skin texture between dorsal and volar skin. This flap is harvested from the dorsum of the proximal phalanx of the index finger based on the first dorsal metacarpal artery, with one or two superficial draining veins and branches of the superficial radial nerve (Fig. 20.3). Very large defects proximal to the interphalangeal crease require some kind of free flap or reversed radial forearm island flap. However, the fibular aspect of the great toe is an excellent donor site for providing sensate and glabrous tissue in a pulp flap to cover the volar aspect of the thumb.11–13 This flap includes the first dorsal metatarsal artery, the superficial vein, the deep peroneal nerve, and the digital nerves.

277

278 Hand and Upper Extremity Reconstruction The shape and texture of the pulp are so similar to those of the normal thumb that there is no need for a secondary operation. Moreover, a new flexor crease will form at the interphalangeal joint by 6 months after surgery (Fig. 20.4). The static two-point discrimination in the lateral side of the great toe is on average 11.3 mm.12,14 In a group of patients after toe flap transfer and nerve repair a mean static two-point discrimination of 6 mm was obtained, which implies that the sensation of the transferred toe flap is more precise than at the donor site.15 Although there are several possible explanations for this, this phenomenon is probably best explained by cortical re-education and adaptation with continuous, repetitive use postoperatively.12,16,17 An aggressive rehabilitative program is essential for sensory restoration. Additionally, in view of the unique characteristics of the skin and subcutaneous tissue covering the pulp of the

Spontaneous healing Skin graft volar V-Y advancement flap

A Small defect B Medium-sized defect C Large defect D Very large defect

Cross-finger flap Cross-side finger flap Palmar advancement flap and its modified procedures Dorsolateral island flap Neurovascular island flap Kite flap Pulp free flap Medial plantar flap Pulp free flap Medial plantar flap Perforator flap Reversed radial forearm island flap

FIGURE 20.1 Classification of pulp defects and options for treatment.

thumb, the medial plantar area is an ideal choice in replacing that lost tissue.18 With regard to the morbidity of the donor site, the medial plantar skin seems more reasonable than harvesting a flap from the pulp of the great toe for thumb reconstruction.

Soft tissue defect of the dorsum Small defects of the dorsum can be covered using a local transposition flap. This is a random pattern flap based on the subdermal plexus and superficial veins. A medium defect can be resurfaced using a de-epithelialized cross-finger flap from the dorsum of the index finger, but the donor site and outer surface of the flap will require a full-thickness skin graft. The kite flap13 is an extremely mobile flap that can reach any surface of the dorsum, as well as being useful in volar reconstruction. Another advantage of the kite flap is its generous size. Large dorsal defects can be repaired with a reversed island flap. The available donor flaps are the radial forearm flap19 or the posterior interosseous flap.20 The radial forearm flap is easy to harvest and reliable, but has severe donor site morbidity. It is also quite bulky and requires the sacrifice of a major artery. The posterior interosseous artery flap is not reliable and is also bulky. Another suitable method is to use a distally based forearm island flap that is vascularized by the perforators of the distal radial artery.21 This flap lies along the axis of the radial artery; the pivot point of its subcutaneous pedicle is 2–4 cm proximal to the radial styloid process. This flap can also be innervated, and is useful for resurfacing the hand. The donor site morbidity is minimal, but flap dissection must be meticulously performed. This flap can also be used to reconstruct compound extensor tendon and skin defects.22,23 Regarding the free flap option, the dorsalis pedis flap used to be very popular because of its close resemblance to the anatomy of the hand and foot.24,25 It is quite versatile in replacing skin, tendons, and nerves in the hand.15,26 The extensor digitorum longus tendon of the second toe can be included in a tendocutaneous flap transfer. This flap must

FIGURE 20.2 Rotation–transposition method for soft tissue replacement on the distal segment of the thumb.

Thumb Reconstruction 279

A

D B

FIGURE 20.3 A Pulp necrosis of the thumb. B Design of the kite flap. C Nerve coaptation between branch of the superficial radial nerve and radial digital nerve of the thumb. D Postoperative view 14 months later.

C


A

B

FIGURE 20.4 A Large pulp defect of the right thumb. Preoperative view. B Postoperative view, 18 months later.

be carefully dissected to minimize scarring in the dorsum of the foot, and an unmeshed, thick split-thickness skin grafting to the foot is recommended.27 Because of the unsightly donor site, this flap is used only in specific situations where compound tissue is needed, but its advantages must outweigh the morbidity at the donor site.

Soft tissue and bone defects For small defects of bone and soft tissue, the thumb can be reconstructed with an iliac bone graft and a reversed fasciocutaneous island flap. Combined soft tissue defects with bone loss of more than 2–3 cm can be reconstructed with a distally based island osteocutaneous flap. The transfer of a vascularized combined osteocutaneous flap is advantageous, because of the ability of the flap to survive in a hypovascular and potentially infected environment. The vascularized bone heals better and can hypertrophy to withstand continuous physical stresses. The available donor flaps are radial,28 ulnar,29 and posterior interosseous.30 The bone contained within these flaps remains viable because of an intact blood supply via the

vascular pedicle. The transferred bone unites directly with the recipient bone without the need for revascularization by creeping substitution. Therefore, the vascularized bone segment provides better union rates and undergoes less resorption than a free bone graft.31 The osteocutaneous radial forearm flap (Fig. 20.5) is the most popular as well as being very reliable.32 A newly designed transverse radial artery forearm flap33 reduces donor site morbidity. The donor defect can be closed by a V-Y advancement of a fasciocutaneous flap based on the ulnar artery, which significantly improves the aesthetic result. Potential radius fracture can be prevented by removing a smaller segment of the bone, using a boat-shaped osteotomy, and ensuring adequate immobilization with a long-arm plaster cast for 6 weeks.34 The osteocutaneous posterior interosseous flap is also recommendable for a single-stage reconstruction of the thumb. The source of the blood supply to the segment of the ulna is mainly musculoperiosteal in its proximal twothirds and fascioperiosteal in its distal third. Therefore, the flap must be harvested from the proximal two-thirds of the ulna with a portion of the extensor pollicis longus muscle.


C

D

FIGURE 20.4, cont’d C Design of the pulp flap on the lateral aspect of the great toe. D Dissected pulp flap with first dorsal metatarsal artery (red arrow), superficial vein (blue arrow), and digital nerve (white arrow).

Compared to the radial osteocutaneous flap, this flap preserves the major arterial supply and can be used even where there is damage to the radial or ulnar arteries or the palmar arch. The ulna is broad and triangular, and its shape at this level allows the segment to be excised while leaving a substantial skeletal framework.30 Immobilization is necessary for only a short period of time, i.e., 1 week.35 This enables both the wrist and the other fingers to start early mobilization and the patient to begin physiotherapy as early as possible.

NAIL AND SOFT TISSUE DEFECT Nonvascularized composite nail grafts for nail defects in both congenital anomalies and traumatic defects have not shown excellent results. To get a predictable final result in nail reconstruction, vascularized nail transfer has been performed. Because thumb nail defects occur concomitantly with injury to adjacent skin, onychocutaneous flaps can be harvested based on the vascular pedicle of the first dorsal metatarsal artery and dorsal vein of the foot (Fig. 20.6). The distal part of the distal phalangeal bone under the nail bed should always be included in the osteo-onychocutaneous

flap, because dissection of the nail bed from the periosteum of the distal phalangeal bone causes iatrogenic injury to the germinal matrix, which can lead to a deformity of the nail plate. Also, it can cause delayed growth of the nail plate because of damage to the subungual vascular arcade during surgical dissection.36

MICROSURGICAL THUMB RECONSTRUCTION When replantation is impossible, emergency or immediate toe-to-hand transfer36,37 is one treatment option based on the concept of early microsurgical reconstruction in acute trauma to the extremities.38 Compared with the later elective operation, immediate toe transfer for thumb reconstruction has several advantages. It allows easy dissection of the intact neurovascular pedicles through the open wound that has not developed fibrosis or scar adhesion. The lack of scar tissue enhances tendon and joint movement after reconstruction. It also reduces the convalescent period by using a single-stage reconstruction, and disability time may be shortened. However, a significant disadvantage of early reconstruction relates to the patient’s lack of understanding of the reconstructive procedure and inability to

C

A

D

B

FIGURE 20.5 A Preoperative photograph of the thumb shows severe crush injury of the soft tissue. B Preoperative X-ray of the left thumb shows comminuted fracture of the proximal phalangeal bone and metacarpal bone. C The osteocutaneous island flap, which is based on the pedicle of reversed radial artery and vena comitantes, includes 8×8 cm of skin flap as well as 6 cm of radius. D Postoperative X-ray taken 20 months later shows healing of the fractures.


E

F

FIGURE 20.5, cont’d E Photograph showing the healed hand, 20 months postoperatively. F Photograph taken 20 months after surgery showing function of the injured hand.

recognize the significance of thumb loss. Preoperative angiography is only recommended if the patient has peripheral vascular disease. Depending on the amount of thumb loss, there are many options for its reconstruction.39,40 In children, reconstructive options are limited to the second-toe option because growth is an important consideration. Second-toe transfer is a useful procedure for a thumb defect distal to or at the metacarpophalangeal joint. Thumb loss proximal to the metacarpal shaft requires pollicization. Figure 20.7 gives recommendations for microsurgical and non-microsurgical reconstructive options in adults.

Defects distal to or at the interphalangeal joint: partial great toe transfer The distal part of the thumb is composed of the nail bed and plate with adjacent dorsal skin, pulp, and distal phalangeal bone. Reconstruction of composite defects of the distal thumb to its original function and appearance is very challenging. This level of amputation does not cause much disability or functional impairment, and some patients may not feel the need for reconstruction, depending on their lifestyle, customs, or cultural background. However, in patients with a high demand for a better esthetic appear-

ance and more refined thumb function, a procedure to make the thumb as natural as possible is needed. The amputation level of the distal thumb can be subdivided into three levels (Fig. 20.8). Level 1 has pulp, partial nail bed, and dorsal skin defects involving less than 60% of the nail width, irrespective of the defect at the distal phalangeal bone. It is reconstructed with an osteo-onychocutaneous flap with a partial nail from the great toe. The distal phalangeal bone under the nail bed is always included in the flap (Fig. 20.9). In level 2, an osteo-onychocutaneous flap with a whole nail from the great toe is used to reconstruct nail bed defects involving more than 60% of the width. In level 3 a partial great toe transfer with arthrodesis of the interphalangeal joint can be performed to reconstruct defects caused by amputation at the level of the interphalangeal joint. In cases where the difference of nail width between the thumb and the great toe is more than 3 mm, the great toe partial-nail-preserving transfer technique is useful41 (Fig. 20.10). There are various methods of great toe-to-hand transfer to restore the interphalangeal joint that play a critical role in key pinch and vice grip for larger objects.42 The mini wraparound flap can be harvested from the great toe, and an arthrodesis of the interphalangeal joint at the recon-


A

B

FIGURE 20.6 A Preoperative view of nail deformity of the right thumb. B Harvested onychocutaneous flap from the left great toe. The red arrow is pointing to the first dorsal metatarsal artery and the blue arrow is pointing to the superficial vein.

structed thumb is performed.43 Approximately 60–66% key pinch and 57% power grip can be achieved compared to the contralateral side.41 With activities of daily life, patients’ complaints are not serious. Arthrodesis of the thumb interphalangeal joint is quite suitable when there are intact metacarpophalangeal and carpometacarpal joints. Primary closure of the donor great toe with a medial skin flap from the remnant great toe is more acceptable after disarticulation at the interphalangeal joint to minimize the morbidity of the donor site.

Operative procedure Dissection of the distal part of the great toe is tedious because the pulp tissue must be freed from the distal phalangeal bone for trimming of its tip. It is difficult to dissect the small digital artery distal to the interphalangeal joint of the great toe. Thus, in most cases, a larger skin flap with a V-shaped lateral pulp area is harvested. Using a retrograde approach44 on the first web space of the foot, the author harvests a composite flap that is pedicled on the first dorsal metatarsal or dorsal digital artery. The artery is skeletonized by a radical resection of the adventitia and the vein dissected with a cuff of perivenous tissue. Digital nerves of

the great toe are also harvested to coapt with the corresponding structures of the thumb. The composite flap always includes a partial distal phalangeal bone, whether the distal phalangeal bone of the recipient site had a bone defect or not. The venous network on the medial aspect of the great toe is more reliable than the first web space. There is usually a prominent branch of the great saphenous vein proximal to the medial nail fold on the tibial aspect of the great toe (Fig. 20.11A). This vein should be included in the flap to prevent necrosis of the remnant skin flap. On the dorsum of the great toe, the subdermal venous plexus should be preserved to close the donor site. After fixation of the harvested toe flap to the distal phalangeal bone of the thumb using K-wires, key skin sutures are placed. In addition, a temporary K-wire is used to fix the bone and prevent kinking of the anastomosed vessels. In cases of partial nail-bed transfer, meticulous repair of the nail beds between the great toe and the thumb is performed using 6/0 chromic catgut, and an artificial nail plate or extracted nail is placed over the repaired nail bed for compression and protection. Secure repair of the nail bed between the great toe and thumb is essential to prevent


C

D

FIGURE 20.6, cont’d C Photo of the revised thumb deformity 4 months after surgery. D Postoperative photo of the donor site.

Microsurgical I Partial great toe flap

Non-microsurgical Local/regional flap Primary closure

II Warp-around flap Web space deepening Trimmed great toe transfer Metacarpal lengthening Whole great toe transfer Osteoplastic reconstruction

III Whole great toe transfer Second toe transfer

1 Osteo-onychocutaneous flap with partial toe nail

Osteoplastic reconstruction Dorsal rotation flap

IV Pollicization Trans-metatarsal second toe transfer after skin flap

FIGURE 20.7 Reconstructive options of the thumb according to the amputation level.

2 Osteo-onychocutaneous flap with whole toe-nail preserving interphalangeal joint

3 Partial great toe transfer with interphalangeal joint arthrodesis

FIGURE 20.8 Microsurgical reconstructive options of partial toe flap transfer according to the amputation level at or distal to the interphalangeal joint.


A

B

FIGURE 20.9 A Preoperative photograph showing the traumatic defect on the radial half of the distal thumb. The defect includes partial nail bed and the distal tip of distal phalangeal bone. B Preoperative design of the osteo-onychocutaneous flap, including the fibular half of the great toe nail.

nail-fold deformities such as splitting or ridge formation. If the nail defect is vertical or straight, it should be converted into an oblique one. The nail-bed repair is performed from the eponychium proximally using an extended incision. Smooth, normal-appearing nail growth may be helped by tight compression of the artificial nail on the repaired nail bed. Arterial anastomosis is performed with the ulnar digital artery at the proximal phalanx, the princeps pollicis artery, or the superficial radial artery at the anatomical snuffbox, depending on the quality of pulsation in the recipient artery of the hand. When the arterial anastomosis is performed at the anatomical snuffbox, a subcutaneous tunnel is made by intraoperative expansion using a Nelaton catheter or silastic drain between two incisions for passage of the vascular pedicle (Fig. 20.11B). This helps avoid the scarring caused by a long incision and the need to perform a skin graft on the reconstructed thumb. Venous anastomosis is performed with a superficial vein at the dorsal aspect of the thumb. In most cases the donor site is repaired primarily without tension. A cross-toe flap or skin graft from the plantar aspect is performed to resurface the donor defect. The purpose of distal thumb reconstruction with toe transfer is focused more on cosmetic appearance than on

functional restoration. Because of this consideration, several articles introduce a short neurovascular pedicle technique for toe transfer to reduce postoperative scarring on the newly reconstructed fingers.45,46 Another advantage is that it avoids the long surgical time required for dissection of a lengthy vascular pedicle. However, these short pedicle procedures are risky in anastomosis of vessels less than 0.8 mm in diameter at the middle phalanx. A moderately long vascular pedicle is good for anastomosis of the vessels at the first web space of the thumb (Fig. 20.11C).

Postoperative management and secondary procedures Intensive postoperative monitoring of the perfusion of the transferred toe and anticoagulation therapy with heparin, aspirin, and prostaglandin E1 is given for 5–7 days. After removal of the temporary K-wire used to block joint motion on day 14, passive movement of the finger is begun. From the third week after the operation, rehabilitation therapy is started to restore sensation, and Coban (3M, St Paul, MN) taping is applied to reduce edema in the transferred toe. At 7–8 weeks after the operation, the remaining K-wires are removed. Secondary procedures such as pulp plasty, nail-


C

D

FIGURE 20.9, cont’d C Placement of the dissected toe flap on the thumb defect. The yellow arrow is pointing to the digital nerve, the blue arrow is pointing to the superficial vein, and the red arrow is pointing to the first dorsal metatarsal artery. D Immediate postoperative view of the flap transfer.

fold plasty or scar revision can be carried out 3–6 months after surgery.

Defects distal to the proximal phalanx: wraparound procedure and trimmed great toe transfer The modified wrap-around flap47 includes skin, nail and nail bed, pulp, and part of the distal phalangeal bone from the great toe as well as a tricortical bone graft from the iliac crest. The neurovascular pedicle is based on the first dorsal metatarsal artery or the dorsalis pedis artery, dorsal venous system, plantar digital nerves, and deep or superficial peroneal nerves. This technique is most suitable for reconstructing thumbs amputated distal to the metacarpophalangeal joint and with complete skin avulsion injuries but intact bone and tendons (Fig. 20.12). The main advantage of this flap is that it is well matched in size in relation to the contralateral normal thumb and morbidity at the donor site is reduced. The disadvantage of this technique is that it is not applicable for thumb reconstruction in children because of the lack of growth potential. The reconstructed thumb may

have limited motion and resorption of the bone graft may occur. The donor site needs a cross-toe flap to cover the defect. The trimmed great-toe transfer is another modification of the great-toe transfer technique for thumb reconstruction.48,49 It includes a reduction of both the bony and the soft tissues on the medial aspect of the great toe to create a more natural-looking thumb. The bone is reduced using a longitudinal osteotomy over the medial aspect of the distal and proximal phalangeal bone. The periosteum and medial collateral ligament of the interphalangeal joint of the great toe are harvested as a proximally based flap. The stability of the new interphalangeal joint can be achieved by simple repair of the periosteum, medial collateral ligament, and joint capsule. Although the cosmetic appearance is better, there is some loss of interphalangeal joint motion. The trimmed toe technique provides the esthetic advantages of the wraparound flap and avoids the problems of bone graft resorption, reduced joint mobility, and tedious dissection. In addition to these procedures, modified twisted-toe flap techniques have been proposed.13,50,51 These are a combination of the wrap-around flap and vascularized joint


E

F

FIGURE 20.9, cont’d E 28-month follow-up photograph showing the appearance of the newly reconstructed thumb. F Postoperative radiographic view of the reconstructed thumb.

transfer or neurovascular cutaneous flap and osteotendinous flap based on a single vascular pedicle. They provide a normal-looking thumb, preserve the epiphyses for future growth, and reduce donor site morbidity, but because they are very complicated these techniques are not popular.

Defects at or near the metacarpophalangeal joint: whole great toe transfer Buncke42 asserted that ‘great toes make great thumbs.’ In cases of amputation at the proximal region of the proximal phalanx or distal metacarpal area with an intact thenar muscle and trapeziometacarpal joint, whole great toe transfer is one of the most acceptable indications. Compared with second toe transfer, it can provide a broad contact pulp area for strong grip and pinch power as well as optimal mobility. Donor site morbidity and a relatively poor appearance are the main pitfalls. The operative procedures have been described in detail elsewhere.52–54 Some procedural tips and guidance are given here.

Hand dissection A criss-cross incision is made on the metacarpal stump to expose both the digital nerves and the arteries. The proxi-

mal ends of the skin flap of the great toe can be inserted into the incisions in the thumb. When the hand has first web space contracture, more skin from the lateral aspect of the great toe is harvested to resurface the defect after contracture release. Through the skin incision, the subcutaneous veins are dissected and the intact digital nerves and superficial radial nerve is tagged. The extensor pollicis longus, abductor pollicis brevis, and adductor pollicis muscles are defined. A healthy bony stump should be created by powered saw for osteosynthesis. Usually, a separate zigzag incision is made on the anatomical snuffbox to dissect the superficial radial artery, one more subcutaneous vein, and the superficial radial nerve. More distally, the first dorsal metacarpal artery is another candidate for the recipient artery. Another separate incision is made on the radial aspect of the wrist to find the flexor pollicis longus tendon.

Foot dissection To make vein dissection easier, a pneumatic tourniquet is applied on the upper thigh; the leg is elevated without exsanguination prior to inflation of the tourniquet. The incision starts at the dorsal aspect of the first web space to determine which artery is dominant to the great toe. According to Wei,52 the first dorsal metatarsal artery is dominant in 70%


A

B

C

E

D

F FIGURE 20.10 A Dorsal view of incision and design of the great toe partial-nail-preserving transfer technique. Shaded region indicated osteotomy site, black line shows the incision. B Volar view of the incision for the design of great toe partial-nail-preserving transfer technique. C Donor site closure of the great toe with partial remnant nail as a fillet flap. D Preoperative photograph of the thumb. E Postoperative view of the reconstructed thumb with great toe nail. F Postoperative view of the donor site.


A

B

FIGURE 20.11 A Photograph showing a prominent branch of the great saphenous vein proximal to the medial nail fold on the tibial aspect of the great toe. This vein should be used for anastomosis. On the dorsum of the great toe, the subdermal venous plexus should be preserved in the dissected skin flap. B To avoid a long incision scar, a subcutaneous tunnel is made by intraoperative expansion with a silastic drain or Nelaton catheter for passage of the vascular pedicle.

of patients, the first plantar metatarsal artery in 20%, and the remaining 10% have a similar caliber in both arteries. Based on the dominant artery, dissection continues in a dorsal or plantar direction. After identification of the subcutaneous venous system, the extensor hallucis longus tendon is dissected to the appropriate length. Next, the deep peroneal nerve and dorsalis pedis artery are dissected distally. On the plantar side, both digital nerves are dissected. The flexor hallucis longus tendon is usually harvested through a separate incision on the proximal plantar area for tendon repair at the wrist. If a longer tendon is needed, an incision can be made around the ankle. After dissecting all the structures needed, the bone or joint capsule is divided. All tissues are divided except arteries and veins, and the tourniquet is released. The surgeon should wait 15–30 minutes for complete reperfusion of the great toe. Irrigation with warm saline or 2% lidocaine is helpful to achieve a more rapid ‘pink-up’ of the toe. If the toe remains pale after this time, careful examination of the main pedicle under the operating microscope is necessary. It may need

meticulous ligation of the tiny branches of the main artery. In addition, the patient’s blood pressure as well as the temperature of the operating room needs to be checked.

Toe-to-thumb reattachment A combination of multiple K-wires fixed interosseously is the most effective way to achieve strong osteosynthesis. Fixation should be checked with a C-arm. The K-wires will be removed serially. Composite joint reconstruction is another good method when the level of the amputation is just at the joint. Joint stability requires strong repair of the capsule and soft tissues between the two joints.55 In the case of amputation at the metacarpal neck, the shape of the metatarsophalangeal joint of the great toe should be made with an angled osteotomy (about 45º) on the dorsal aspect of the metatarsal head to preserve the plantar aspect of the first metatarsal head and the sesamoid bone (Fig. 20.13). The metatarsal head is fixed to the metacarpal bone to convert a hyperextension joint into a flexion joint.


C FIGURE 20.11, cont’d C Dissected partial toe flap with moderately long vascular pedicles. Yellow arrows show both digital nerves, the blue arrow is pointing to the superficial vein, the red arrow is pointing to the first dorsal metatarsal artery.

To achieve a strong repair of the tendons, the author uses a modified Becker’s technique56 or Pulvertaft interlace suture for both flexor and extensor tendons. After tendon repair, the range of motion of the interphalangeal joint should be checked by passive flexion and extension of the wrist. Arterial repair can now be performed. Once perfusion is obtained, all the nerves are sutured. One or two veins are repaired. The skin is sutured without tension. Small skin grafts may be used for open areas. The management of the donor site is not easy. The bulging part of the metatarsal bone should be trimmed and the skin can be closed primarily, without tension.

Donor site problems Even though a successful great toe transfer can provide satisfactory results in both function and appearance, donor site complications should be minimized. Some patients complain of occasional mild discomfort of the foot and

intolerance to cold.57 After a whole great toe transfer, the weightbearing area shifts to the second and third metatarsal heads. There is no significant complaint of metatarsalgia after the wound has healed. Additionally, in sports activities it may be difficult to ‘push off’ from the involved foot. This is caused by the descent of the first metatarsal head secondary to proximal migration of the sesamoid bones and increased plantar flexion of the first metatarsal shaft.58 To prevent these complications, at least 1 cm of the proximal phalanx should be preserved. Wound healing at the donor site is also very important to maintain a normal gait. Primary closure of the donor site provides early and stable wound healing compared to a skin graft or any type of flap procedure. The failure rate of toe transfer is reported to be 2.5– 7.2%.59–61 The primary factors in failure are the anatomical variation of the first dorsal metatarsal artery and the diameter and pattern of the branches of the main artery. Other factors leading to failure include smoking, age, and the condition of the patient’s coagulation system. The most important consideration during the dissection of the artery is the meticulous ligation of any small branches of the main artery. Rarely after toe dissection there is a lack of reperfusion in the toe after release of the tourniquet, even 20 or 30 minutes later. In this case, the status of the main artery should be rechecked under a microscope. If any small branch of the main artery remains open, it should be ligated to prevent segmental spasm.62 If there is no problem involving the vessels, irrigation with warm saline is the best way to obtain reperfusion. In the difficult case of lack of perfusion, even after perfect arterial anastomosis, first recheck the condition of the recipient artery proximally under a microscope. If a problem cannot be identified, a sympathetic block on the brachial plexus is needed to achieve vasodilatation. Awakening the patient from general anesthesia is another way to stimulate perfusion. Intensive monitoring of perfusion status is mandatory for 5–7 days postoperatively. To further guarantee complete survival of the transferred toe, the threshold for reexploration should be very low. Any circulatory problem should be checked under a microscope in an operating room immediately. Unfortunately, even after all possible efforts to achieve normal circulation, persistent circulatory problems can occur. In this case, a tubed groin flap can be the last resort to salvage the transplanted bone.63

SECOND TOE TRANSFER Compared to great toe transfer, second-toe transfer is indicated in a proximal metacarpal amputation because there is less donor site morbidity associated with harvesting the second toe. Because of the need to maintain the great toe metatarsophalangeal joint for push-off, the use of the great toe for proximal metacarpal amputation is not suitable. In this case, second-toe transfer is used for thumb reconstruction instead of great toe transfer, although the postoperative appearance is not great. This procedure usually needs a


A4 A2 A1

A3

A5

A6

FIGURE 20.12 A Schematic view of the wrap-around procedure as described by Morrison and O’Brien (1980).

preliminary flap to provide redundant soft tissue around the metacarpal area to wrap around the second toe (Fig. 20.14). For a single-stage reconstruction a combined dorsalis pedis flap with transmetatarsal second-toe transfer is also possible, although the problems at the donor site can be substantial. A V-shaped incision is made on both the dorsal and the plantar aspects of the foot. This provides adequate skin coverage for both donor and recipient sites. The procedure for foot dissection is not much different from that of a great toe transfer. If there is not enough soft tissue for coverage, the metatarsal bone should be harvested with the interosseus muscle, but it is better to add redundant soft tissue to the thumb in the first stage using a groin flap. It is not advisable to take precious soft tissue from the foot to add coverage in the hand. The arc of motion in the metatarsophalangeal joint is mainly dorsiflexion, and this may cause a hyperextension deformity of the thumb. This can be prevented by shortening the volar plate and using an angled osteotomy of the metatarsal head. Regarding donor site closure, the intermetatarsal ligaments should be repaired between the great and third toes.

Temporary K-wire fixation between metatarsals may be used to ensure a narrow interdigital web space and preserve the appearance of the donor site.

POLLICIZATION Since the introduction of the microvascular toe-to-thumb transfer procedure, pollicization using a normal index or ring finger for thumb reconstruction has become less favored. However, in reconstructing a thumb amputated at or proximal to the metacarpophalangeal joint, this procedure is still useful, considering the amputation level. Pollicization of the index finger is much easier and safer than that of other fingers, because there is no need for the cross-over of vessels, nerves, or tendons. The middle finger spontaneously replaces the function of the transferred index finger. Moreover, the excision of the second metacarpal bone results in a deepening of the first web space. The presence of thenar muscle function is critical for obtaining satisfactory results in pollicization.64 However, even if the thenar muscles are not present, the recon-


C

B

D FIGURE 20.12, cont’d B Preoperative view of an avulsion amputation of the left thumb. C Wrap-around flap is harvested. Blue arrows show the superficial veins, yellow arrow shows the digital nerve, red arrow shows the first dorsal metatarsal artery. D The appearance of reconstructed thumb 43 months postoperatively.


Hyperextension joint

Stance

FIGURE 20.13 Schematic view of an angled osteotomy and shortening of the plantar plate. This procedure facilitates a hyperextension joint in its conversion into a flexion joint.

Sesamoid bone

Toe-off

Angled osteotomy + Shortening of plantar plate

Flexion joint

B

A

C FIGURE 20.14 A Traumatic amputation of the left thumb at the level of the metacarpal head. B A distant groin flap is utilized to provide soft tissue around the thumb. C Photograph showing the plantar plate shortening by elliptical resection after the second toe is harvested.


D

E

G

F

structed thumb may function as a stationary post to oppose the other fingers for grasping and pinching. If necessary, a secondary opponensplasty using the ring flexor digitorum superficialis or abductor digiti quinti minimi muscle can provide more opposition. There are some differences when comparing pollicization with congenital cases. In adult traumatic situations, both flexor and extensor tendons should be divided and resutured to balance the tension in the new thumb, with its different length and position. Also, because of previous scarring in the region, secondary procedures including tenolysis or opponensplasty may be required. Functional results have shown a 61º total arc of motion of the inter-

FIGURE 20.14, cont’d D Postoperative photograph showing transferred toe. E Postoperative functional photograph showing range of motion of implanted toe. F Radiograph of the transferred second toe. G Postoperative view of healed donor site.

phalangeal and metacarpophalangeal joints, and 69% and 41% grip and pinch strength, respectively, compared to the contralateral uninjured thumb.64

‘ON-TOP PLASTY’ Where thumb amputation is combined with multiple digital amputations, a short thumb ceases to be functional. To achieve a more useful length, a short amputated digit can be transferred on top of the amputated thumb as an island flap by including the phalangeal bone (Fig. 20.15). This procedure is called ‘on-top plasty.’65 This type of pollicization was introduced by Littler66 in 1952 as the


A

C

B

FIGURE 20.15 A Preoperative photograph showing partial amputation of the right thumb and complete amputation of the index finger. B X-ray showing amputation of the right thumb and index finger with destruction of the PIP joint of the long finger. C On-top plasty with neurovascular island flap from the long finger.

D

E

FIGURE 20.15, cont’d D Postoperative view. E Postoperative functional view. F Postoperative radiograph.

F

298 Hand and Upper Extremity Reconstruction TABLE 20.1 Comparison of available toe-to-hand transfer techniques Whole great toe

Trimmed great toe

Wrap-around

Second toe

Partial great toe

Function mobility sensation

++++ ++++

+++ ++++

+ ++++

++ ++

+ ++++

Appearance

+++

++++

++++

+

++++

Strength

++++

+++

+++

++

+++

Donor Site function appearance

+ +

++ ++

+++ +++

++++ ++++

++++ +++

Technical difficulty

easy

difficult

more difficult

easy

most difficult

Complication

none

none

bone resorption no growth

claw-finger

none

neurovascular pedicle method of digital transposition for subtotal reconstruction of the thumb. In multidigital amputations this technique can be applied at any level of thumb amputation. In correct terminology, reconstruction of the amputated thumb with heterodigital transfer as an island flap is true pollicization, but this procedure is based on the pattern of a free flap and should be called ‘free on-top plasty.’ In multiple digital amputations in both hands, an injured digit can be transferred for reconstruction of the contralateral thumb. This technique has its advantages in composite tissue reconstruction as a single procedure and provides acceptable results in sensation and appearance.

CONCLUSION Toe transfer is the most complex option for thumb reconstruction and can cause significant psychological stress to both surgeon and patient. For patients, it requires prolonged anesthesia and a long rehabilitation time. For surgeons, the operation demands a high level of microsurgical skill to yield an esthetically and functionally acceptable thumb. Regardless of whether the operation is performed electively or in emergency treatment of acute hand injuries, the indications should be highly restricted and the use of toe transfer decided on only after thorough analysis of the advantages and disadvantages of each method, as well as consideration of the overall condition of the patient (Table 20.1).

REFERENCES 1. Moberg E. Aspects of sensation in reconstructive surgery of the upper extremity. J Bone Joint Surg [Am] 1964; 46: 817–825. 2. Dellon AL. The extended palmar advancement flap. J Hand Surg [Am] 1983; 8: 190–194. 3. Hueston J. Local flap repair of fingertip injuries. Plast Reconstruct Surg 1966; 37: 349–350. 4. Argamaso RV. Rotation–transposition method for soft tissue replacement on the distal segment of the thumb. Plast Reconstruct Surg 1974; 54: 366–368. 5. Posner MA, Smith RJ. The advancement pedicle flap for thumb injuries. J Bone Joint Surg 1971; 53A: 1618–1621.

6. Pho RW. Restoration of sensation using a local neurovascular island flap as a primary procedure in extensive pulp loss of the fingertip. Injury 1976; 8: 20–24. 7. Brunelli F. Dorso-ulnar thumb flap. Ann Chir Main Memb Sup 1993; 12: 105–114. 8. Littler JW. Neurovascular pedicle transfer of tissue in reconstructive surgery of the hand. J Bone Joint Surg [Am] 1956; 38: 917. 9. Littler JW, Markley JM. Digital neurovascular island skin flap. In: Strauch B, Vasconez LO, Hall-Findlay EZ, eds. Grabb’s encyclopedia of flaps. Vol. II. Boston: Little, Brown, 1990; 887–891. 10. Foucher G, Braun JB. A new island flap transfer from the dorsum of the index to the thumb. Plast Reconstruct Surg 1979; 63: 344–349. 11. Daniel RK, Terzis J, Midgley RD. Restoration of sensation to an anesthetic hand by a free neurovascular flap from the foot. Plast Reconstruct Surg 1976; 57: 275–280. 12. Strauch B, Tsur H. Restoration of sensation to the hand by a free neurovascular flap from the first web space of the foot. Plast Reconstruct Surg 1978; 62: 361. 13. Foucher G, Merle M, Maneaud M, Michon J. Microsurgical free partial toe transfer in hand reconstruction: a report of 12 cases. Plast Reconstruct Surg 1980; 65: 616–627. 14. Morrison WA, O’Brien BM, MacLeod AM, Gilbert A. Neurovascular free flaps from the first web of the foot. J Hand Surg 1978; 3: 235. 15. Woo SH, Kim JS, Kim HH, Seul JH. Microsurgical reconstruction of partial thumb defects. J Hand Surg [Br] 1999; 24: 161–169. 16. May JW, Chait LA, Cohen BE, O’Brien BM. Free neurovascular flap from the first web space of the foot in hand reconstruction. J Hand Surg 1977; 2: 387–393. 17. Woo SH, Choi BC, Oh SJ, Seul JH. Classification of the first web space free flap of the foot and its applications in reconstruction of the hand. Plast Reconstruct Surg 1999; 103: 508–517. 18. Lee HB, Tark KC, Rah DK, Shin KS. Pulp reconstruction of fingers with very small sensate medial plantar free flap. Plast Reconstruct Surg 1998; 101: 999–1005. 19. Song R, Gao Y, Song Y, et al. The forearm flap. Clin Plast Surg 1982; 9: 21–26. 20.Penteado CV, Masquelet AC, Chevrel JP. The anatomic basis of the fascio-cutaneous flap of the posterior interosseous artery. Surg Radiol Anat 1986; 8: 209–215. 21. Jeng SF, Wei FC. The distally based forearm island flap in hand reconstruction. Plast Reconstruct Surg 1998; 102: 400. 22. Reid CD, Moss LH. One-stage flap repair with vascularised tendon grafts in a dorsal hand injury using the ‘Chinese’ forearm flap. Br J Plast Surg 1983; 36: 473–479. 23. Lu LJ, Gong X, Lu XM, Wang KL. The reverse posterior interosseous flap and its composite flap: Experience with 201 flaps. J Plast Reconstruct Aesthet Surg 2007; 60: 876–882.

Thumb Reconstruction 299 24. Daniel RK, Terzis J, Midgely RD. Restoration of sensation to an anesthetic hand by a free neurovascular flap from the foot. Plast Reconstruct Surg 1976; 57: 275–281. 25. McCraw JB, Furlow LT. The dorsalis pedis arterialized flap. A clinical study. Plast Reconstruct Surg 1975; 55: 117–185. 26. Woo SH, Seul JH. Optimizing the correction of severe postburn hand deformities by using aggressive contracture releases and fasciocutaneous free-tissue transfers. Plast Reconstruct Surg 2001; 107: 1–8. 27. Samson MC, Morris SF, Tweed AEJ. Dorsalis pedis flap donor site: Acceptable or not? Plast Reconstruct Surg 1998; 102: 1549–1554. 28. Biemer E, Stock W. Total thumb reconstruction: a one-stage reconstruction using an osteo-cutaneous forearm flap. Br J Plast Surg 1983; 36: 52–55. 29. Guimberteau JC, Goin JL, Panconi B, Schuhmacher B. The reverse ulnar artery forearm island flap in hand surgery: 54 cases. Plast Reconstruct Surg 1988; 81: 925. 30. Costa H, Smith R, McGrouther DA. Thumb reconstruction by the posterior interosseous osteocutaneous flap. Br J Plast Surg 1988; 41: 228–233. 31. Cutting CB, McCarthy JG, Knize DM. Repair and grafting of bone. In: McCarthy JG, ed. Plastic surgery. Vol. 1. Philadelphia: WB Saunders, 1990; 583–629. 32. Yajima H, Tamai S, Yamauchi T, Mizumoto S. Osteocutaneous radial forearm flap for hand reconstruction. J Hand Surg [Am] 1999; 24: 594–603. 33. Ahn HC, Choi MS, Hwang WJ, Sung KY. The transverse radial artery forearm flap. Plast Reconstruct Surg 2007; 119: 2153–2160. 34. Bardsley AF, Soutar DS, Elliot D, Batchelor AG. Reducing morbidity in the radial forearm flap donor site. Plast Reconstruct Surg 1990; 86: 287–292. 35. Akin S, Ozgenel Y, Ozcan M. Osteocutaneous posterior interosseous flap for reconstruction of the metacarpal bone and soft-tissue defects in the hand. Plast Reconstruct Surg 2002; 109: 982–987. 36. Woo SH, Lee GJ, Kim KC, et al. Immediate partial great toe transfer for the reconstruction of composite defects of the distal thumb. Plast Reconstruct Surg 2006; 117: 1906–1915. 37. Wei FC, Epstein MD, Chen HC, et al. Microsurgical reconstruction of distal digits following mutilating hand injuries: results in 121 patients. Br J Plast Surg 1993; 46: 181–186. 38. Godina M. Early microsurgical reconstruction of complex trauma of the extremities. Plast Reconstruct Surg 1986; 78: 285–292. 39. Morrison WA, O’Brien BM, MacLeod AM. Experience with thumb reconstruction. J Hand Surg [Br] 1984; 9: 223–233. 40. Kleinman WB, Struickland JW. Thumb reconstruction. In: Green DP, Hotchkiss RN, Pederson WC, eds. Green’s Operative hand surgery, 4th edn. New York: Churchill Livingstone, 1999; 2096. 41. Woo SH, Seul JH. Distal thumb reconstruction with a great toe partial-nail preserving transfer technique. Plast Reconstruct Surg 1998; 101: 114–119. 42. Buncke HJ, Valauri FA. Reconstruction of the thumb with a trimmed-toe transfer technique [Discussion]. Plast Reconstruct Surg 1988; 82: 514–515. 43. Adani R, Cardon LJ, Castagnetti C, Pinelli M. Distal thumb reconstruction using a mini wrap-around flap from the great toe. J Hand Surg [Br] 1999; 24: 437–442. 44. Wei FC, Silverman RT, Hsu WM. Retrograde dissection of the vascular pedicle in toe harvest. Plast Reconstruct Surg 1995; 96: 1211–1214.

45. Endo T, Nakayama Y. Short-pedicle vascularized nail flap. Plast Reconstruct Surg 1996; 97: 656. 46. Spokevicius S, Vitkus K. Reconstruction of the distal phalanx of the fingers by free toe-to-hand transfer. J Hand Surg [Br] 1991; 16: 169–174. 47. Morrison WA, O’Brien BM, MacLeod AM. Thumb reconstruction with a free neurovascular wrap-around flap from the big toe. J Hand Surg [Am] 1980; 5: 575–583. 48. Wei FC, Chen HC, Chuang CC, Noordhoff MS. Reconstruction of the thumb with a trimmed-toe transfer technique. Plast Reconstruct Surg 1988; 82: 506–515. 49. Upton J, Mutimer K. A modification of the great-toe transfer for thumb reconstruction. Plast Reconstruct Surg 1988; 82: 535–538. 50. Tsai TM, Aziz W. Toe-to-thumb transfer: a new technique. Plast Reconstruct Surg 1991; 88: 149–153. 51. Iglesias M, Butron P, Serrano A. Thumb reconstruction with extended twisted toe flap. J Hand Surg [Am] 1995; 20: 731–736. 52. Wei FC. Toe-to-hand transplantation. In: Green DP, Hotchkiss RN, Pederson WC, Wolfe SW, eds. Green’s Operative hand surgery, 5th edn. New York: Churchill Livingstone, 2005; 1835. 53. Vedder NB, Maser BM: Thumb reconstruction: Microvascular methods. In: Mathes SJ, Hentz VR. Plastic surgery. Vol. 7 The hand and upper limb: Part I. Philadelphia: WB Saunders, 2006; 253–280. 54. Morrison W. Microsurgical thumb reconstruction. In: Strickland JW, ed. The hand and upper limb. Vol 11. Edinburgh: Churchill Livingstone, 1994; 133–150. 55. Wilson CS, Buncke HJ, Alpert BS, Gordon L. Composite metacarpophalangeal joint reconstruction in great toe-to-hand free tissue transfers. J Hand Surg [Am] 1984; 9: 645–649. 56. Wassermann RJ, Howard R, Markee B, et al. Optimization of the MGH repair using an algorithm for tenorrhaphy evaluation. Plast Reconstruct Surg 1997; 99: 1688–1694,. 57. Lipton HA, May JW Jr, Simon SR. Preoperative and postoperative gait analyses of patients undergoing great toe-to-thumb transfer. J Hand Surg [Am] 1987; 12: 66–69. 58. Poppen NK, Mann RA, O’Konski M, Buncke HJ. Amputation of the great toe. Foot Ankle 1981; 1: 333–337. 59. Buncke HJ, Buncke GM, Lineaweaver WC, et al. Bad results after large toe to thumb transplantation. Ann Chir Main Memb Sup 1991; 10: 513–516. 60. Foucher G, Moss ALH. Microvascular second toe to finger transfer: a statistical analysis of 55 transfers. Br J Plast Surg 1991; 44: 87–90. 61. Gu YD, Zhang GM, Chen DS, et al. Toe-to-hand transfer: an analysis of 14 failed cases. J Hand Surg [Am] 1993; 18: 823–827. 62. Lister GD, Kalisman M, Tsai TM. Reconstruction of the hand with free microneurovascular toe-to-hand transfer: experience with 54 toe transfers. Plast Reconstruct Surg 1983; 71: 371–386. 63. Ozkan O, Chen HC, Mardini S, et al. Principles for the management of toe-to-hand transfer in reexploration: toe salvage with a tubed groin flap in the last step. Microsurgery 2006; 26: 100–105. 64. Ishida O, Taniguchi Y, Sunagawa T, et al. Pollicization of the index finger for traumatic thumb amputation. Plast Reconstruct Surg 2006; 117: 909–914. 65. Kelleher JC, Sullivan JG, Baibak GJ, Dean RK. ‘On-top plasty’ for amputated fingers. Plast Reconstruct Surg 1968; 42: 242–248. 66. Littler JW. Subtotal reconstruction of the thumb. Plast Reconstruct Surg 1952; 10: 215–226.

CHAPTER

Congenital Hand Procedures

21

Scott N. Oishi, Peter Carter and Marybeth Ezaki

Many children are born with congenital anomalies that affect the upper extremity. In the embryo, upper limb bud formation begins 4 weeks after fertilization. With rapid growth and differentiation, all limb structures are present by 8 weeks after fertilization. Congenital upper extremity anomalies are present in 0.1–0.2% of newborns.1 Most of these anomalies occur spontaneously without any family history, and the cause of many is not known; however, some medications have been implicated, including thalidomide, warfarin, phenytoin, and valproic acid. Illicit drugs such as cocaine, along with alcohol and cigarette smoking, have also been associated with the development of congenital hand anomalies.2 Hand anomalies can be very disturbing psychologically to both the patient and parents. Polydactyly is the most common hand anomaly, with an incidence of 1 per 600 live births, and is 10 times more common in African-Americans. Isolated syndactyly is also a common hand anomaly, with an incidence of 1 per 2000– 2500 live births. Bifid thumb, or radial polydactyly, has an incidence of about 1 per 3000 live births.1,3,4 The timing of early surgical reconstruction must be weighed against the anesthetic risks and patient safety issues. Some anomalies are associated with systemic disorders that must be addressed before any surgical intervention. An example of this is radial dysplasia, which is frequently associated with other systemic conditions/syndromes that need to be evaluated prior to any reconstructive procedure. In this chapter we will discuss reconstructive procedures for some of the most common congenital anomalies of the upper extremity.

in Caucasians than in African-Americans.2–4 It results from lack of segmentation of the digits. Syndactylies can be classified into simple (Fig. 21.1) or complex (Fig. 21.2), incomplete (Fig. 21.3) or complete (see Fig. 21.1) depending on their composition. A simple syndactyly has no bony attachment between the two digits, whereas a complex syndactyly has bony connections between the two digits. Incomplete or complete describes whether the skin connection involves a portion of the fingers or extends all the way to the tips.

Indications and contraindications for surgery Timing of syndactyly release is not the same for every patient. Ideally, syndactyly reconstruction should take place after about 1.5 years of age, at which time the child is larger and important anatomic structures can be more easily identified. However, complex syndactylies and syndactylies involving the first and/or fourth web spaces may benefit from earlier release because of the tethering effect of different lengths of digits that can cause deformity with differential growth (Fig. 21.4).

Preoperative history and considerations Although rare, some syndactylies can be associated with syndromes. For this reason careful examination of the entire patient is essential. Also, it is our feeling that a patient with syndactyly affecting both sides of a digit should undergo staged reconstruction instead of releasing both sides at once, to avoid potentially devascularizing the central digit (Fig. 21.5).

Simple syndactyly SYNDACTYLY Isolated syndactyly occurs in 1 in 2000–2500 live births. It is twice as common in boys as in girls, and more common

Whether the syndactyly is complete or incomplete does not matter in the surgical approach. A standard dorsal flap is outlined with double-opposing Z-plasties on the dorsal

301

FIGURE 21.2 Complex syndactyly involving bony fusion of the terminal phalanges of the fingers. FIGURE 21.1 Simple syndactyly with no bony attachments between the fingers.

FIGURE 21.4 For border digits, the differential length of the ring and little finger, if left untreated, will cause deviation of the ring finger towards the little finger. This will cause growth disturbance for both digits, and this type of syndactyly may need to be released before 1 year of age.

FIGURE 21.3 Incomplete syndactyly with soft tissue attachment that does not extend to the tips of the fingers.

and volar portions of the syndactyly (Fig. 21.6). In the palm the appropriate position of the web is determined and marked. Surgery begins by incising the dorsal flap. Next, the volar web-space incision is made and the neurovascular pedicles are identified and isolated. Careful dissection of the neurovascular pedicle is crucial, and often limits the proximal extent of the syndactyly release. The double-opposing Z-plasty incisions are then carefully made, preserving the neurovascular bundles. If the syndactyly is complete, pulp flaps may be necessary to provide adequate tip coverage.13 After separation of the digits, the flaps are inset and a template of the soft tissue defects is made. Often, there is

Congenital Hand Procedures 303

A

B FIGURE 21.5 A For complex syndactyly involving four fingers, one should plan the staging operation efficiently to minimize the number of surgical procedures. This child will have syndactyly releases between the index and middle fingers and the ring and little fingers in order to avoid operating on both sides of the digits and prevent injuring the vascular structures on both sides of the finger. B Postoperative view showing release of the border digits using a combination of skin grafts and skin flaps.

fibrous tissue between the fingers that needs to be removed before the flaps are inset. In our opinion, skin grafts are essential in trying to prevent web-creep postoperatively. It is important to have appropriate tension on the skin grafts and flaps (Fig. 21.7). Healing by secondary intention often leads to significant postoperative scarring and deformity. A long-arm cast is placed for 3–4 weeks to allow wound healing.

compromise. However, we have found it useful to release the tips of the adjacent involved fingers. We have found that this releases the tethering effect (see Fig. 21.4), which facilitates later formal syndactyly reconstruction.


Complex syndactyly The design of skin incisions is very similar to that for simple syndactyly, but the tips of the syndactylies need special consideration, especially when the nail is involved. They often need pulp flaps and full-thickness skin graft (FTSG) to give the best postoperative appearance. At times several adjacent fingers may be involved. If this is the case we usually perform syndactyly reconstruction in a staged fashion. We try not to completely separate adjacent web spaces in one operation because of the risk of vascular

●

Ensure adequate length of dorsal flap Careful design of Z-plasties Liberal use of skin grafts

Complications and side-effects ●

●

Web creep Attempt to prevent this by using appropriate skin flaps and skin grafts. If this occurs, deepening of the web is usually required. Neurovascular injury This can occur during separation of the digits. The best way to avoid it is with careful


A

A

B FIGURE 21.7 The flaps fit into place and the open wounds will be covered with skin grafts from the groin, or in this case from the hypothenar area.

B FIGURE 21.6 A typical flap incision design with the proximal flap fitting into the web space and zigzag incisions to fit either side of the released fingers.


●

●

dissection, frequently assessing the location of the neurovascular bundles. Hypertrophic/keloid scarring This can occur despite appropriate surgery. May also occur if there is skin flap and/or skin graft loss. This may require repeat grafting. If more severe or recurrent, may require more aggressive adjunctive treatment (i.e. methotrexate).14 Inadequate tip coverage May require pulp grafts from ulnar hand or foot. These are taken as pinch grafts from either the ulnar side of the hand or side of the big toe. This provides a better match for the glabrous skin than the usual FTSG taken from the groin or wrist.

Postoperative care ●

●

Long-arm cast for 3–4 weeks. No reason to examine wounds earlier. If still unsure of wound healing, we place the patient back in a long-arm cast for an additional 2–3 weeks. Scar contracture. Try to avoid with carefully designed flaps. If it occurs, release and skin grafting may be needed.

Conclusion Syndactyly reconstruction is a very common congenital hand surgery procedure. Careful patient evaluation and design of surgical flaps will optimize the final outcome. However, it should be noted that these patients often require secondary revisions as they go through growth spurts. This is especially true if the initial syndactyly reconstruction is performed at an early age. FIGURE 21.8 Type A postaxial polydactyly.

POSTAXIAL POLYDACTYLY Postaxial (ulnar) polydactyly is divided into two types, depending on the development of the supernumerary digit. Type A is a well-developed digit (Fig. 21.8), whereas type B is pedunculated and rudimentary. Postaxial polydactyly is 10 times more common in African-Americans than in Caucasians. In blacks, it usually is an isolated finding and inherited in an autosomal dominant fashion. In whites it is frequently syndromic and autosomal recessive.5

Indications and contraindications ● ●

Type A – must be corrected in the operating room. Type B – can be treated in a nursery or clinic. We find that this is very easily done in our clinic and saves the child a general anesthetic.

Preoperative history and considerations The most important factor is determining which type of postaxial polydactyly is present. If type B, it can be easily treated in the nursery or outpatient clinic. Type A should

be treated in the operating room. Because of the increased anesthetic risks in newborns, the operative procedure should be delayed until at least 6 months of age.

Operative approach Type A Under general anesthesia an elliptical incision is made around the base of the supernumerary digit. The digit is explored to check for any functional parts that can be saved and transferred to the hand. At times a bony connection can be present and must be addressed carefully. The neurovascular bundles to the digit are identified and transected. The skin is closed with 6/0 plain absorbable suture and the extremity placed in a long-arm cast for 2–3 weeks to allow wound healing.

Type B The base of the rudimentary digit is prepared and injected with 1% lidocaine plus epinephrine. A ligaclip is then applied around the base (Fig. 21.9). The hand is then wrapped for 2 weeks, leading to autoamputation of the supernumerary digit.

306 Hand and Upper Extremity Reconstruction the type of polydactyly present. Type B may be treated easily in the nursery or clinic, whereas type A requires surgical excision in the operating room.

PREAXIAL (RADIAL) POLYDACTYLY In the past this has been termed duplicated thumb, but it should more appropriately be termed bifid or split thumb. Each bifid (split) thumb is usually small and the two together would equal one normal-sized thumb. The incidence is about 1 in 3000 live births, with most being sporadic in inheritance and unilateral in presentation. The exception is the triphalangeal thumb, which is usually autosomal dominant. As opposed to postaxial (ulnar) polydacytyly, preaxial polydactyly is more common in Caucasians and other systemic problems are usually not present.6–8 The most common classification system is that described by Wassel in 1969, which categorizes bifid thumbs based on skeletal replication. Type IV (replication of the distal and proximal phalanges) is the most common.9

Indications and contraindications Usually the authors perform thumb reconstruction between the ages of 1 and 2 years, when there is a lower anesthetic risk and the structures are larger, for ease of identification.

Preoperative history and considerations FIGURE 21.9 Ligaclip ligation of the pedunculated extra digit is an effective mode of treatment in the nursery. The distal digit will necrose and fall off spontaneously.


Correct identification of the type of postaxial polydactyly. Ensuring that the base of a type B postaxial polydactyly is small enough to be treated with the appropriate size of ligaclip.

Complications The most common complication of autoamputation is a residual nubbin. On occasion this can be quite large and require a secondary revision procedure. The patient undergoing treatment of a type A postaxial polydactyly may have a well-developed nerve that must be transected carefully to prevent a painful neuroma.

Postoperative care Local wound care is all that is needed for the majority of these conditions.

Conclusion Postaxial polydactyly is a common congenital anomaly. Appropriate treatment mandates correct identification of

Before surgery, the thumbs must be assessed to determine which one is the most dominant. Although this is usually the ulnar thumb, careful observation for joint mobility and stability is mandatory before determining which thumb to remove. Although we will describe reconstruction based on type of split thumb, the general goals are the same for every type. The more hypoplastic thumb is ablated, and the soft-tissue elements from the ablated thumb are added to the retained thumb to improve the aesthetic appearance and function.

Operative approach Types I and II split thumbs Although some authors have advocated the Bilhout–Cloquet procedure, in general we have not found this to be reliable. We prefer to ablate the radial thumb and reconstruct the ulnar thumb for types I (Fig. 21.10) and II. The first step is to outline the proposed surgical incision line. This will frequently require the incorporation of a flap taken from the ablated thumb to provide soft-tissue coverage for the radial side of the reconstructed thumb. After the incisions are made, the skin flaps are carefully raised (Fig. 21.11). We use a proximal zigzag incision to examine the extensor tendons to both thumbs. The extensor tendon is centralized, with augmentation from the ablated thumb if necessary. This is done by transferring the extensor tendon from the ablated digit to the body of the remaining extensor tendon. If this is a type II configuration, it is important to dissect the collateral ligament from the ablated thumb


A

FIGURE 21.10 This is a type 1 bifid thumb with a shared base of the distal phalanx. This classification system is quite simplistic, but useful in which the odd numbers have a shared base of the phalange while even numbers have separation of the base of the phalanges.

using a periosteal sleeve. The periosteal sleeve is then sutured to the appropriate area on the retained thumb for collateral ligament reconstruction. The articular surface of the proximal phalanx may need to be narrowed to better reconstitute the interphalangeal (IP) joint. The incision is closed with chromic sutures (Fig. 21.12). A Kirschner wire is used to stabilize the IP joint. A long-arm cast is placed for 5–6 weeks, followed by pin removal.

Types III and IV thumbs Draw the incisions carefully to permit excision of the leastdeveloped thumb and preserve the excess skin as a flap for later use. For types III and IV (Fig. 21.13A) a proximal zigzag incision is used to explore the extensor and flexor systems as well as the thenar intrinsic muscles. If the extensor and flexor systems on the ablated thumb are well developed they may be used to augment the existing system. Also, it is important that the extensor and flexor systems are centralized on the reconstructed thumb. If this is not done the

B

action of the tendons will cause eccentric pull on the finger instead of true flexion/extension. This can tend to angulation of the thumb. The radial collateral ligament is dissected off with a periosteal sleeve. In the majority of cases, the articular surface of the metacarpal needs to be narrowed to improve joint congruity and bony alignment. At this point the reconstructed thumb is assessed for angulation, which may benefit from a closing wedge osteotomy for more severe deformity. It is important to perform this carefully to stay out of the epiphysis. A Kirschner wire is placed (Fig. 21.13B) for bone and joint stabilization, the radial collateral ligament is repaired and the thenar intrinsic muscle is reattached, if necessary. A long-arm cast is placed for 5–6 weeks, after which time the pin is removed.

Types V and VI thumbs Reconstruction for types V and VI is similar to that for types III and IV, but requires more intrinsic muscle reconstruction and may require first web-space Z-plasty.


FIGURE 21.12 Results after radial thumb excision and radial ligament reconstruction. A K-wire is used to protect the ligament and tendon reconstruction.

sor/flexor tendons, joint congruity, collateral ligament reconstruction, and skeletal alignment. Treatment of joint instability frequently requires arthrodesis, whereas malalignment may require exploration, tendon recentralization, and/or joint realignment. FIGURE 21.11 Exposure showing the periosteal flap (arrow) harvested from the excised radial thumb to reconstruct the radial collateral ligament.

Optimizing outcomes ● ● ● ● ● ●

Correct design of incisions Assessment of flexor/extensor tendons of the ablated thumb Recentralization of flexor/extensor tendons Skeletal alignment and joint congruity Collateral ligament preservation and reconstruction Temporary Kirschner wire fixation to allow soft-tissue healing/osteotomy healing

Complications and side-effects The most common complications relate to joint instability and deformity of the reconstructed thumb. The best way to try to avoid these is to ensure centralization of the exten-

Conclusion Proper reconstruction for preaxial polydactyly depends on the type of polydactyly. The initial surgery for thumb reconstruction offers the best chance for an ideal result. This may require tendon centralization, joint reconstruction, osteotomy, and/or collateral ligament reconstruction.

RADIAL DYSPLASIA Radial dysplasia represents a spectrum of longitudinal deficiency in radial growth. It is usually categorized into four types depending on the deficiency in the radius.10 Type I (Fig. 21.14A) and some type II (Fig. 21.14B) patients do not require surgical treatment. If there is significant radial deviation, surgical treatment may be helpful in improving function. Types III (Fig. 21.14C) and IV (Fig. 21.14D) often require surgical treatment to correct the deformity.


A

B

FIGURE 21.13 A This is type IV bifid thumb with a shared metacarpal. Reconstruction must pay attention to reconstituting the radial collateral ligament using a periosteal flap. B Appropriate skin design will produce an aesthetically pleasing reconstructed thumb.

Indications and contraindications ●

●

●

Treatment is usually not necessary in patients with type I and some type II radial deficiencies. The patient must have the ability to get the fingers to the mouth with the wrist in the surgically altered straight position. All patients should undergo stretching prior to surgical release. A recent study has reported that preoperative external fixation placement may be the most effective stretching treatment; however, we do not utilize this on a regular basis in our practice.

Preoperative history All patients warrant work-up for syndromes and associated conditions because many have syndromes such as TAR

(thrombocytopenia absent radius), Holt–Oram, Fanconi’s, or VACTERL (vertebral abnormalities, anal atresia, cardiac defect, tracheotsophageal fistula, renal abnormalities, limb abnormalities). These conditions must be addressed prior to any surgical treatment.

Operative approach Many authors have advocated centralization procedures for patients with radial dysplasia. We have found soft-tissue release and bilobed flap reconstruction to be a better procedure for our patients (Fig. 21.15). A bilobed flap is carefully outlined over the dorsum of the wrist. The incisions are made and the flaps elevated (Fig. 21.16). The extensor tendons, flexor tendons, and median nerve are identified. These structures are usually


A

FIGURE 21.14 Radial dysphasia showing the progressive loss of the radius, with the most extreme type IV case where the radius is absent.

in a very abnormal radial position and careful identification is essential. The soft-tissue tethering is then released. We do not advocate much stripping at the distal ulna to prevent injury to the blood supply to the physis of the ulna. After this is performed, the wrist is placed in a neutral position and a 0.062 in Kirschner wire (or larger) is passed across the ulnocarpal joint. The flaps are then rotated into place and closed using absorbable sutures (Fig. 21.17). A longarm cast is then applied.

Optimizing outcomes ● ● ●

●

Adequate preoperative stretching Correct flap design Careful identification of median nerve and tendons prior to releasing radial soft tissue Pinning of wrist in neutral to allow wound/ flap healing

B

Complications and side-effects The blood supply to the physis of the ulna can be damaged if too much dissection is performed in that region. This can ultimately lead to a very short forearm. Flap loss can occur if the flap is not adequately designed, or if the wrist is not stabilized postoperatively to allow flap healing. The median nerve and tendons must be identified.

Postoperative care The patient is placed in a long-arm cast for 4 weeks. At that time, the pin is removed and a splint fashioned for wear.

Conclusions The authors have found that soft-tissue release and bilobed flap reconstruction is a reliable, effective procedure for


C

D FIGURE 21.14, cont’d

FIGURE 21.15 Bilobed reconstruction in which the redundant skin on the ulnar wrist after centralization is used to augment the skin deficiency over the radial wrist after centralization.

FIGURE 21.16 The flap elevation technique providing excellent full exposure of the wrist during this operation.


FIGURE 21.17 Final closure of the flap without the traditional requirement for excision of skin on the ulnar side of the wrist.

patients with radial dysplasia who need surgical reconstruction. The procedure is very dependable, and offers a predictable outcome with little morbidity. Although there is certainly a risk of recurrence, we feel that it is no higher than that seen with centralization or radialization procedures. These latter procedures certainly have a higher risk of significant morbidity than our soft-tissue release/bilobed flap reconstruction procedure. Whatever choice is made for surgical treatment, it is important to remember that these patients must have a careful preoperative evaluation to assess underlying syndromes, thereby optimizing their safety and appropriateness for surgery.

FIGURE 21.18 Type II hypoplastic thumb with underdeveloped hypothenar muscle. This can be treated with a Huber transfer, in which the abductor digiti minimi muscle can be transferred across the palm to reconstitute the thenar cavity and provide muscle function for the thumb.

HYPOPLASTIC THUMB Hypoplastic thumb is most commonly seen as a component of radial dysplasia.11 There are five categories of thumb hypoplasia, ranging from minimal deficiency (type I) to complete absence (type V).12 Appropriate surgical management is related to the type of hypoplasia present.

Indications and contraindications Patients with type I hypoplastic thumbs generally do not require surgical treatment. Patients with types II (Fig. 21.18) and IIIA can generally benefit from opponensplasty and web-space deepening. This will provide opposition function as well as an increase in first web space. Patients with types IIIB, IV, and V (Fig. 21.19) require pollicization for reconstruction. Type IIIB thumbs usually require pollicization because of the presence of a very unstable thumb carpometacarpal (CMC) joint.

Preoperative history and considerations Because many of these patients have radial dysplasia, they require appropriate evaluation to rule out other, more severe underlying problems. See the radial dysplasia section for a list of these.

Operative approach Types II and IIIA hypoplastic thumbs These patients usually need increased first web space and opposition. They have a stable carpometacarpal (CMC) joint but significant laxity at the metacarpophalangeal (MCP) joint. We approach this condition using a four-flap Z-plasty and ring finger superficialis opponensplasty. The Z-plasty incisions are made (Fig. 21.20A,B) and the first dorsal interosseous fascia is released. The ulnar aspect of the thumb MCP joint is then exposed. Next, a small incision is made over the radial aspect of the thumb MCP joint to expose the distal metacarpal and MCP joint. The A-1 pulley of the ring finger is opened and the superficialis tendon identified. An incision is made over the volar forearm to expose and identify the ring finger superficialis proximally. The tendon is then transected distally and delivered into the proximal wound. It is then rerouted around the FCU tendon at the wrist proximal to the pisiform, and passed through a subcutaneous tunnel to the radial thumb incision. A trough is made at the neck of the metacarpal and the tendon is passed from radial to ulnar. The thumb is placed in an opposition position and the tendon sutured to the ulnar base of the proximal phalanx. This technique not only accomplishes the opponensplasty, but also stabilizes the ulnar MCP joint. The incisions are


A

FIGURE 21.19 This patient has absence of the thumb and a good indication for index pollicization.

closed and the Z-plasty flaps rotated and sutured (Fig. 21.20C).

Types IIIB, IV, and V hypoplastic thumbs These children have thumbs that are usually not reconstructable, therefore the optimum procedure is pollicization. The flaps for pollicization are carefully outlined on the index finger and the hand (Fig. 21.21). The palmar incision is made and the neurovascular bundles are identified and isolated (Fig. 21.22). The radial digital artery may be absent, but the transferred index finger is dependent on the common digital artery to the index and middle fingers. The arterial branch to the middle finger is ligated and the common digital nerve is mobilized as proximally as possible to allow transposition of the index finger without tethering of the digital nerve. It is essential to assess adequate vascular inflow to the index finger before continuing with the procedure. If this cannot be assured, the procedure must be

B

aborted. The A-1 pulley of the index finger is opened and the flexor tendons as well as the neurovascular bundles are isolated with vessel loops (Fig. 21.23). Attention is then turned to the dorsum of the finger, where the outflow veins are isolated and extensor tendons freed after incising the dorsal skin flaps. The intermetacarpal ligament is next divided to mobilize the index finger. The interosseous muscles are then taken down off their insertions distally and mobilized proximally. Careful attention to preservation of the collateral ligaments is important. A proximal osteotomy at the base of the second metacarpal is performed, with epiphyseodesis being performed distally. The shaft of the index metacarpal is then removed (Fig. 21.24). The MCP joint is placed in hyperextension and a 0.035 or 0.045 in Kirschner wire is passed across the MCP joint in a retrograde fashion. The base of the proximal index metacarpal is shaped to accommodate the hyperextended MP joint, and 2/0 non-absorbable sutures are placed around this area. The


B

A

FIGURE 21.20 A This patient had an FDS transfer that was looped around the flexor carpi ulnaris tendon as a pulley to provide thumb abduction. B Patients with a thumb–index web space can be released using a four-flap Z-plasty to deepen the web space, which can also augment the results of the FDS abductor plasty. C Insetting of the four-flap Z-plasty.

C


A

B FIGURE 21.21 A popular flap option is the option proposed by Buck and Gramcko. The C flap will eventually form the thumb–index web space, the B flap will rest on the palmar side of the thumb and the A flap will interdigitate between the C and the B flaps.

MCP joint is then placed in its new position and the Kirschner wire advanced across this area. After correct position is assured, the 2/0 non-absorbable sutures are placed at the base of the proximal phalanx. It is mandatory that the neurovascular bundles are examined to determine that no kinking exists. Next, the interosseous muscles are repositioned into the dorsal base of the middle phalanx (lateral bands). The extensor tendons are then examined. If two tendons exist then the radial one is shortened so that it can insert on the dorsoradial base of the middle phalanx. The ulnar extensor tendon is then imbricated to shorten it to the proper length. Skin flaps are rotated then closed (Fig. 21.25) and the vascularity of the index finger is assessed. A dressing and long-arm cast are then applied.


●

●

Proper flap design Careful identification and dissection of the neurovascular bundles Ensure no kinking of the neurovascular bundles once the pollicized digit is set in place Proper position and length of pollicized digit

FIGURE 21.22 The ulnar and radial neurovascular bundles are identified. The transferred thumb can survive on an intact ulnar neurovascular bundle because in some cases the radial digital artery is very small or may not be present.

Complications and side-effects If the viability of the pollicized digit is questionable, the first step is to ensure that the neurovascular bundle is not compressed or kinked. Both the room and the digit must be warm. A local anesthetic wrist nerve block is placed for postoperative pain control and potential vasodilation effect. These steps are usually adequate to treat a digit that may have vasospastic problems.

Postoperative care A long-arm cast is placed for 6 weeks. The pin is removed after cast removal and a splint is applied for an additional 6 weeks.


FIGURE 21.23 The A-1 pulley should be released to allow adequate transfer of the index finger, with the flexor tendon acting as the FPL tendon for the newly created thumb.

Index finger transposed to be used as thumb

Base and head of index metacarpal serves as CMC joint

Part of metacarpal removed

A

B

FIGURE 21.24 A The metacarpal is removed, but the base of the metacarpal is left intact and the head of the metacarpal will serve as the CMC joint, the PIP joint will serve as the MCP joint, and the DIP joint will serve as the IP joint of the newly created thumb. B Recession of the index finger to make a new thumb.

FIGURE 21.25 The flap sutured in place.

A

B


Conclusion Hypoplastic thumb usually has an accompanying component of radial dysplasia. For this reason proper preoperative evaluation is mandatory. Reconstruction is based on the type of hypoplasia present. Type I usually requires no treatment. Types II and IIIA require web-space deepening and opponensplasty, and types IIIB, IV, and V benefit from pollicization. As a result, it is imperative to diagnose the type of hypoplasia correctly.

REFERENCES 1. Kozin S. Upper-extremity congenital anomalies. J Bone Joint Surg Am 2003; 85: 1564–1576. 2. Man L, Chang B. Maternal cigarette smoking during pregnancy increases the risk of having a child with a congenital digital anomaly. Plast Reconstruct Surg 2006; 117: 301–308. 3. Netscher D. Congenital hand problems: terminology, etiology and management. Clin Plast Surg 1998; 25: 537–552.

4. McCarroll H. Congenital anomalies: A 25-year overview. J Hand Surg 2000; 25A: 1007–1037. 5. Watson BT. Post-axial type-B polydactyly: prevalence and treatment. J Bone Joint Surg Am 1997; 79: 65–68. 6. Cohen M. Thumb duplication. Hand Clin 1998; 14: 17–27. 7. Ogino T, Ishii S, et al. Long-term results of surgical treatment of thumb polydactyly. J Hand Surg 1996; 21(A): 478–486. 8. Ezaki M. Radial polydactyly. Hand Clin 1990; 6: 65–68. 9. Wassel HD. The results of surgery for polydactyly of the thumb. Clin Orthop 1969; 64: 175. 10. Bayne CG, Klug MS. Long-term review of the surgical treatment of radial deficiency. J Hand Surg (Am) 1987; 12: 169–179. 11. James M, Green H, et al. The association of radial deficiency with thumb hypoplasia. J Bone Joint Surg Am 2004; 86: 2196–2205. 12. Plancher K, Kahlon R. Diagnosis and treatment of congenital thumb hypoplasia. Hand Clin 1998; 14: 101–118. 13. Golash A, Watson J. Nail fold creation in complete syndactyly using Buck–Gramcko pulp flaps. J Hand Surg (Br) 2000; 25B: 11–14. 14. Muzaffar A, Rafols F, et al. Keloid formation after syndactyly reconstruction: associated conditions, prevalence, and preliminary report of a treatment method. J. Hand Surg 2004; 29A: 201–208.

CHAPTER

Techniques in Reconstruction of the Burned Hand

22

C. Scott Hultman

INTRODUCTION

Burn wound characteristics

Reconstruction of the burned hand requires a multidisciplinary approach that not only combines elements of hand, plastic, and burn surgery, but also utilizes resources that include critical care, nursing, occupational therapy, and rehabilitative medicine.1–9 Management of the burned hand is essentially the art of matching the needs of the patient with surgical solutions that yield the best functional and aesthetic outcomes. The challenge to the healthcare provider is to create and implement a surgical plan that addresses the goals of resuscitation, resurfacing, reconstruction, rehabilitation, and reintegration, all of which overlap but evolve as the patient moves towards reaching his or her potential for recovery.

The size, location, and depth of the burn wound all affect the management and prognosis. Even isolated, relatively small burns of the hand can dramatically affect final function. Both isolated and non-isolated hand burns can impair the patient’s ability to perform activities of daily living, delay discharge, and prevent return to work. For example, both the electrician with median nerve disruption after electrical injury and the textile worker with a boutonnière deformity after an industrial press injury may not be able to re-enter the workplace at their previous level of competence, despite appropriate care, reconstruction, and rehabilitation. Perhaps the most important determinant of outcome is burn wound depth. First-degree burns are notable for erythema and edema but have no tissue loss and heal without difficulty. Second-degree, superficial partial-thickness burns are characterized by painful blistering but will heal via regenerating dermal elements, provided adequate wound care is available. Second-degree, deep partial-thickness burns have desquamated areas, with significant dermal destruction. Such burns may take longer than 3 weeks to heal and will benefit from excision and grafting. Thirddegree full-thickness burns are leathery, dry, and insensate; they will only heal by eschar separation and secondary contraction, and require early excision and grafting to optimize function. Fourth-degree burns damage structures invested by the skin and can include injury to neurovascular structures, tendon, muscle, and bone; amputation and/or flap coverage is often required to achieve wound closure.

RESUSCITATION Like all patients with thermal injury, individuals with acute hand burns must undergo a carefully coordinated resuscitation that includes determination of mechanism, assessment of burn wound depth, restoration of perfusion, damage control of other injuries, appropriate wound care, occupational therapy, and consideration of systemic issues.

Mechanism The first step in taking care of the patient with a hand burn is obtaining a reliable history to determine the mechanism of injury. Thermal injury can be due to a spectrum of etiologies, all of which yield a different constellation of signs and symptoms. Causes of burn injury include scald, contact, flame, chemical, and electrical. Patients with both highand low-voltage electrical injuries can have considerable tissue damage that is not reflected by the size of the external burn.7 Another particularly challenging type of burn is the hot-press injury, in which patients have a crush component in addition to the thermal component.

Restoration of perfusion Patients with circumferential hand burns, electrical injury, or large burns requiring aggressive resuscitation may develop impaired hand perfusion that mandates immediate inter-

319

320 Hand and Upper Extremity Reconstruction vention.6 Compartment syndromes of the forearm and hand occur as edema increases due to local and systemic capillary leakage, and as interstitial pressures exceed filling pressures. Circumferential full-thickness burns often benefit from prophylactic escharotomy, whereas patients who develop compartment pressures greater than 25 mmHg or symptoms of pain and paresthesia require fasciotomy. Waiting until the patient develops pulselessness to perform a compartment release falls below the accepted standard of care. Digital escharotomy remains a controversial procedure but may be indicated on rare occasions. Complete

upper extremity fasciotomies include release of the dorsal and volar forearm, carpal tunnel release, thenar and hypothenar fasciotomy, and dorsal hand interosseous fasciotomies (Fig. 22.1A–E).

Damage control In addition to compartment release to restore perfusion to the hand, other damage control procedures include fracture stabilization, reduction of dislocated joints, acute nerve decompression, debridement of clearly non-viable tissue,

A

B

C

D

FIGURE 22.1 A–E This 36-year-old electrician, who sustained an arc flash injury from a high-voltage transformer, later underwent skin grafting of the fasciotomy sites and the dorsum of the hand. Complete upper extremity fasciotomies for compartment syndrome after an electrical injury include release of the volar and dorsal compartments, the carpal tunnel, and the thenar, hypothenar, and interosseous muscles. The pronator quadratus must also be explored and decompressed, as this muscle can sustain significant injury, given its location deep to the flexors and in continuity with the radius and ulna. Bone is a poor conductor of electricity and considerable heat is generated in the relatively small cross-sectional area of the wrist.

E

Techniques in Reconstruction of the Burned Hand 321 and amputation. Patients with electrical injury require multiple debridements in the operating theater, prior to definitive coverage, to ensure that all necrotic tissue has been removed.

Wound care Currently accepted wound care practices for thermal injury of the hand include the application of an antimicrobial cream that is changed daily. Burn wounds have classically been described to include a zone of coagulation (necrosis), a zone of stasis, and a zone of hyperemia. The depth and size of the wound can increase if perfusion is impaired (from inadequate resuscitation), or if the wound becomes infected (from local organisms or distant sources, such as a pneumonia). To reduce bacterial and fungal colonization, various antimicrobial agents have been used and each has variable penetration of the eschar. In our practice, we use silver sulfadiazine initially, switching to sulfamylon for pseudomonal infections and silver nitrate for fungal infections.

Occupational therapy In acute management of the burned hand, the early and proactive delivery of occupational therapy is important. Range of motion must be maintained because stiffness will develop rapidly to cause tendon, volar plate, and joint adhesions. Splinting in the intrinsic plus position to maintain metacarpophalangeal (MCP) joints in flexion and proximal interphalangeal (PIP) joints in extension, and the wrist in slight extension, is critical to keep the collateral ligaments maximally stretched. Occupational therapy is particularly important in critically ill patients who cannot participate in their own care. The overall value of occupational therapy, whether immediately after injury, perioperatively, or through the reconstruction period, cannot be overemphasized. To paraphrase a famous quote: ‘the sins of the burn surgeon can be covered by the glove of the therapist.’

Systemic issues Because more than 80% of patients admitted to a burn center have hand involvement,6 most patients with hand burns have multiple factors influencing their overall care. A partial list of competing priorities includes mechanical ventilation for inhalation injury, dialysis for renal failure, anticoagulation for deep venous thrombosis prophylaxis or therapy, and use of vasoactive agents for cardiac failure or septic shock. Furthermore, patients with large total body surface area wounds may have a limited number and limited quality of donor sites. The surgical team must remain cognisant of all of these issues but not lose sight of the principles of early excision and coverage of the hand, in combination with vigilant occupational therapy.

RESURFACING Following stabilization of the acutely burned hand, wound excision and closure become the most important goals.

Although superficial partial-thickness wounds heal within 1–2 weeks and rarely require grafting, biologic dressings such as Biobrane and cultured fibroblasts have been advocated but are cost-prohibitive, compared to standard antimicrobial cream. Deep partial-thickness wounds are observed for 2–3 weeks and excised if not healing within that period. Full-thickness burns of the hand almost always require excision and definitive closure.

Excision For most partial-thickness hand burns, tangential excision of the eschar and mid-dermal elements is the procedure of choice. Using a Weck blade or Goulian knife with a guard, the surgeon removes devitalized tissue in a tangential plane until fine punctate capillary bleeding is encountered, indicating a viable bed. Extreme care must be used when excising eschar over the dorsum of the fingers, as the extensor apparatus can easily be injured. The advantage of this technique is that a layer of deeper dermis is preserved, providing structural, mechanical, and vascular support for a skin graft. The disadvantage is that significant blood loss can occur, approaching 1 mL for every cm2 of tissue excised. To minimize blood loss, we immediately wrap the hand in a phenylephrine-soaked compressive gauze. The Versajet (Smith & Nephew, Hull, UK), which debrides at a fixed depth via pulsed hydrosonic energy, can also be used as an adjunct to tangential excision. For full-thickness burn wounds, however, we prefer to perform initial full-thickness excision under tourniquet control. The excision is carried out in a suprafascial plane, leaving paratenon intact to support a skin graft. The advantage of this approach is that it limits blood loss and optimizes visualization of critical structures such as tendons, nerves, and vessels. A disadvantage is the potential overexcision of viable tissue. The tourniquet is then deflated to observe the viability of the prepared surface. Additional sharp debridement is usually required. Location of the burn wound also guides our decisionmaking. We have a low threshold for excision of burn wounds over the dorsal surface of the hand, especially over joints. In contrast, the thick glabrous skin of the palmar surface has excellent potential for regeneration, and therefore these burn wounds are rarely excised or acutely grafted.

Temporary coverage When the viability of the wound is uncertain, as in the case of electrical or hot-press injuries, or when definitive coverage is not available, temporary coverage is indicated.10 We prefer to use fresh cadaveric split skin grafts, colloquially known as ‘homograft,’ for wound closure, because of this material’s relative availability, ease of use, comparatively low cost, excellent take rate, and resistance to infection. Other options include acellular dermal matrix (Alloderm), bilaminate skin substitutes (Integra), and bioprosthetic dermal analogues (Biobrane). Although all of these materials will promote wound closure, all require definitive

322 Hand and Upper Extremity Reconstruction replacement with epithelium. We have also abandoned culture keratinocytes in the temporary or definitive closure of burn wounds because of the exorbitant cost (>$100,000 to resurface 10% total body surface area), the 3-week delay in preparing these grafts, mechanical fragility, and difficulty in application.11

Grafting The gold standard for wound closure of the acutely burned hand remains thick (14/1000-in), split-thickness sheet autografts.12–14 Full-thickness grafts are reserved for late reconstructive procedures, and meshed, thin autografts are used only if there is significant concern for bed viability or if the patient has limited donor sites. Despite an improved take rate, meshed grafts have an increased incidence of contracture and an inferior aesthetic outcome. Although full-thickness grafts have almost no contraction, provide more robust tissue for vital areas of the hand, and can become reinnervated, full-thickness grafts are limited in size and have an uncertain take rate in freshly excised burn wounds. Donor locations for split-thickness grafts include the thighs and buttocks; those for full-thickness grafts include the distal ulnar forearm, antecubital fossa, medial arm, and lateral groin.

wrist, and distal forearm, and can be used in combination with skin grafts to resurface a fairly large area. Furthermore, the flap can be easily thinned with liposuction or direct lipectomy, withstands repeat elevation for multiple reconstructive procedures, and has an excellent esthetic result. Our only admonition is that this flap should be used cautiously in patients with seizure disorders (which may result in disruption), advanced age (resulting in elbow and shoulder stiffness), and psychiatric illness (specifically anxiety disorders, which may become exacerbated).

Amputation Careful consideration of the patient’s functional goals, including potential for rehabilitation, may argue toward amputation as the best method of wound closure (Fig. 22.6A–D). For example, the laborer who has a fullthickness, fourth-degree chemical burn to the dorsum of the index finger would benefit from ray amputation. The power linesman who sustains a 10 000 volt injury, with a nonviable hand/forearm and persistent myoglubinuria, requires a below-elbow amputation, if the elbow can be safely preserved. Fillet flaps are also an excellent source of innervated tissue to resurface other portions of the hand. Amputation facilitates wound closure and may be life-saving.

Flaps

RECONSTRUCTION

Indications for flap coverage of the acute or late burn wound include inability of the bed to support a skin graft or skin substitute, and the need to cover vital structures with vascularized tissue.15–27 Examples include a child with exposed extensor tendons from a contact burn, or an electrician who undergoes delayed ulnar nerve reconstruction with a sural nerve graft. Limited areas of the hand can be resurfaced with several different types of intrinsic flap, such as the innervated kite flap from the index finger (Fig. 22.2A–F), flag flaps based on dorsal digital vessels, cross-finger flaps, and dorsal metacarpal artery flaps. Regional options include adipofascial turnover flaps from the forearm (Fig. 22.3A–E), as well as reverse flow flaps, based on the posterior interosseous, radial (Fig. 22.4A–E), or ulnar vessels (the last two of which require a patent superficial palmar arch). Distant flaps, which need to be divided at a second stage, include the groin flap (Fig. 22.5A–D), the periumbilical perforator flap, and the random-pattern chest flap. Finally, free tissue transfer may be the best option for wound coverage, when regional flaps may lie within the zone of injury or are unable to provide an adequate surface area. Options used in our practice have included serratus, latissimus, and rectus abdominis for muscular coverage; lateral arm, parascapular, and anterolateral thigh skin for fasciocutaneous coverage; and omentum for massive defects of the upper extremity. The most reliable and frequently used flap in our practice remains the groin flap. In addition to providing a large paddle of vascularized skin, this flap can be harvested quickly and confidently, can be inset anywhere on the hand,

Despite receiving excellent care during the resuscitative and resurfacing phases, patients with hand burns may develop complications and deformities that require reconstruction to correct functional deficits.28–34 Multiple problems may coexist that affect the delicate relationships between joints, tendons, ligaments, nerves, and skin. In addition to focusing on the underlying problem, the surgeon must also consider the soft tissue envelope and be prepared to import vascularized tissue to ensure a successful reconstruction. In burn patients, hand surgery is truly the surgery of the skin and its contents.

Stiffness Perhaps the most common sequela after burn injury to the hand is stiffness. The exact etiology may include a number of different causative factors: persistent edema, shortening of collateral ligaments, tendon adhesions, capsular contractures, and constriction of the soft tissue envelope. All of these conditions benefit from range of motion exercises (active and passive) and splinting. Occasionally, patients require manipulation of joints under anesthesia with concurrent steroid injections. Occupational therapy must continue through the postoperative period to retain these gains in function.

Swan-neck deformity Intrinsic tightness may occur as a result of an imbalance between the flexor and extensor tendons and lateral bands

Techniques in Reconstruction of the Burned Hand 323

A

B

C

D

E

F

FIGURE 22.2 A This 42-year-old electrician sustained a focal left hand burn that was allowed to heal by secondary intention, resulting in a numb index finger, as well as a Tinel’s sign over the second metacarpal, proximal to the zone of injury. B Exploration of the palm revealed disruption of the radial digital nerve. C End-to-end neurorrhaphy and neurolysis of the ulnar digital nerve plus release of the palmar contracture. D The wound was covered with an innervated kite flap harvested from the dorsum of the index finger, over the proximal phalanx. Contracture along the radial side of the middle finger was released with a five-flap ‘jumping-man’ z-plasty. E Postoperative healing of donor site for the innervated kite flap. F Postoperative healing of the recipient site of the innervated kite flap and healing of the z-plasty contracture release.


A

B

C

D

FIGURE 22.3 A–E This 67-year-old man sustained full-thickness burns to the volar wrist after contact with a floor heater following a seizure. His radial artery developed a mycotic aneurysm that subsequently ruptured. Following acute burn wound excision and ligation of the radial artery, the median nerve and superficial flexor tendons were covered with an adipofascial turnover flap, based on the distal radial artery perforators, plus a skin graft.

E

from the lumbricals and interosseous muscles. Patients with an ischemic insult to the intrinsic muscles of the hand or with inadequate splinting develop shortening of the lateral bands, yielding intrinsic tightness and a deformity that results in hyperextension of the MCP and PIP joints, and flexion of the DIP joints. Intrinsic tightness can be tested by confirming that flexion of the MCP joint improves the ability to passively flex the PIP joint (Bunnell’s sign). If occupational therapy is unsuccessful in re-establishing the length of lateral bands, surgical therapy to correct intrinsic tightness includes division of the lateral bands.

Tendon adhesions In contrast to intrinsic tightness, patients may develop extrinsic tightness from adhesions that limit the excursion of the extensor tendons. Passive PIP flexion is more difficult when the MCP joint is first flexed. Of note, adhesions can form directly under skin grafts, in areas that have healed by secondary re-epithelialization, and even outside the zone of injury. Surgical therapy involves tenolysis of involved tendons, which is combined with postoperative hand therapy and immediate range of motion exercises.


A B

C

D

E

Boutonnière deformity Damage to the central slip of the extensor apparatus may result in boutonnière deformity, leading to flexion of the PIP joint and hyperextension of the DIP joint. The mechanism for this injury involves lateral and volar displacement of the lateral bands, which now serve as flexors rather than as extensors of the PIP joint. This occurs when the central slip is damaged, e.g., from direct thermal or crush injury, or from exposure and dessication after the thin, dorsal skin has been burned and lost. Acute management includes a combination of splinting and pinning in extension, and soft tissue coverage is secured via flap or graft. Late reconstruction can be quite challenging and depends on the condition of the overlying skin, the degree of subluxation, the condition of

FIGURE 22.4 A This 54-year-old woman sustained deep partialthickness burns to the hand and forerarm from a scald injury. She underwent sheet grafting to the thumb and meshed split-thickness grafting to the wrist. B She formed a hypertrophic scar, and subsequently developed severe median nerve compression. C, D The scar was excised and resurfaced with a septocutaneous, reverse-flow, radial forearm flap, following an extended carpal tunnel release. E Postoperative photograph showing healed radial forearm flap.

the joint capsule and cartilage, and the residual stiffness of the finger.29 Options that can be pursued include plication of the lateral bands for mild cases; a figure-of-8 tendon graft to restore the full function of the central slip; and 30º arthrodesis with buried Kirchner pins and cerclage wire. The extensor apparatus and joint are approached from the dorsal surface of the finger through a curvilinear incision.

Mallet finger Injury to the distal portion of the extensor apparatus over the DIP joint can result in disruption of the extensor tendon where it inserts onto the distal phalanx, leading to a mallet finger. Splinting in extension may correct the acute defor-


B A

D C FIGURE 22.5 A This 61-year-old man sustained full-thickness chemical burns to the dorsum of the hand and underwent failed attempts at resurfacing with split skin grafts and, on a subsequent occasion, a bilaminate skin substitute. B He ultimately required a pedicled groin flap that was divided 3 weeks later and thinned with each syndactyly release. C, D Postoperative photographs showing healed flaps to the fingers.

mity, but arthrodesis is usually performed for chronic deformities. Fusion of the DIP joint with 0–5º of flexion is approached through an H incision, to preserve any remaining germinal matrix, and is secured via a longitudinal wire or compression pin after residual cartilage is removed.

Although the PIP joints may require a dorsal approach to repair a damaged central slip, or to perform arthrodesis, we usually perform a volar release of the flexion contracture, which allows for access to the volar plate, followed by fullthickness skin grafting.

Claw hand

Palmar and digital contractures

The combined forces of dorsal skin contracture, intrinsic tightness, extrinsic tightness, joint stiffness, ligamentous and volar plate shortening, and injury to the extensor apparatus conspire to produce the claw hand. This deformity has variable presentations, but typically includes hyperextension of the MCP joints and flexion contractures of the PIP joints, both of which dramatically impair hand function and need to be corrected. We proceed with reconstruction of the claw hand via a staged approach, first addressing the soft tissue envelope and performing a groin flap or free tissue transfer to improve soft tissue coverage. At the second stage we treat the MCP region via a combination of extensor tenolysis, dorsal capsulotomy, and splinting in flexion.

A frequently observed effect of deep burns to the volar surface of the hand is contracture of the palm that limits full extension of the digits and mobility of the thumb. These contractures are released under tourniquet control and resurfaced with full-thickness grafts. The surgeon must pay particular attention to identifying and preserving the neurovascular bundles, which can be quite superficial. The superficial palmar fascia is also incised to permit full release. We usually delay release in children until they are over 2 years of age, unless the contracture has impaired growth of the digit. Patients are splinted for several weeks as the graft is incorporated. Choice of donor site has a major impact on the color and texture of the resurfaced hand.


A

B

C

D

FIGURE 22.6 A This 33-year-old powerlineman sustained a high-voltage injury to his left upper extremity, which was treated via fasciotomy and eventually thumb amputation. B Poor inflow via an attenuated radial artery, combined with a thrombosed ulnar artery, precluded safe pollicization or toe-to-thumb transfer. Instead, the patient underwent late neurolysis of the median and ulnar nerves, complete flexor tenolysis, and tendon transfer of the flexor pollicis longus to the index finger flexor digitorum profundus, which had been disrupted by the original injury. D He is now able to use a prosthetic thumb, has been able to lower his golf handicap to 18 (which is considerably better than the author’s), and has recently returned to work as a supervisor.

Web space deformities Burn injury to the web space, with or without grafting, may result in acquired syndactyly and adduction contractures, reversing the slope of inclination and preventing full abduction. For dorsal syndactylies extending to the mid-portion of the proximal phalanx, the web space can be reconstructed via tissue re-arrangement, using VM-plasty or STARplasty to reline the cleft with supple tissue from the digital sidewalls.31,32 For acquired syndactylies extending beyond the mid-portion of the proximal phalanx, full release requires the use of diamond-shaped full-thickness skin grafts to resurface the web space. Contractures of the first web space are particularly important to address as they involve not only thumb abduction, but also thumb opposition and flexion.28 In addition to releasing the web space skin contracture, which is typically dorsal, the surgeon may need to address an adduction contracture that is caused by fibrosis and shortening of the

adductor pollicis muscle. After releasing the fascia and, when necessary, the insertion of the adductor pollicis, percutaneous K-wires are then used to place the thumb metacarpal temporarily in maximal abduction, and the defect is resurfaced with a full-thickness skin graft. First web space contractures that do not involve the adductor pollicis may not require skin grafting and can be released and resurfaced via a five-flap ‘jumping man’ Z-plasty.

Nail-plate abnormalities Burn injury to the germinal matrix, sterile matrix, or eponychial skin may result in a hook-nail deformity, nailplate grooving, proximal nail exposure, or dystrophic nail with chronic paronychia.30 These deformities may have significant psychological stigmata, in addition to the functional problems related to grip and grasp. Whereas the eponychium can be relined with a full-thickness skin graft,

328 Hand and Upper Extremity Reconstruction or the matrix repaired with donor material from the toe, severe injuries are best served by ablation of the nail through surgical resection of the germinal matrix.

Nerve compression syndromes Patients with signs or symptoms of peripheral nerve compression may benefit from decompression. The pathophysiology can include a combination of extrinsic compression from the burn scar, intrinsic compression from traditional points of fascial and ligamentous compression, and/or preexisting occult disease. Although carpal tunnel syndrome, cubital tunnel syndrome, and ulnar nerve compression at the wrist are the most common syndromes encountered, we have also observed and treated compression of the superficial radial nerve, posterior interosseous nerve, anterior interosseous nerve, and peroneal nerve. Tendon transfers, such as opponensplasty for median nerve palsy, may be indicated for long-standing or permanent nerve dysfunction. Caveats for surgical intervention include 1) corroboration of findings on physical examination with mechanism and history of symptoms, 2) identification of a Tinel’s sign to help guide the site of decompression, 3) release of all potential points of constriction (including the deep motor branch of the ulnar nerve during Guyon’s canal release), 4) combining multiple releases under one tourniquet pass, 5) minimizing incision length when in the zone of injury, and 6) consideration of coverage with vascularized tissue. We obtain nerve conduction studies only when history and physical examination are not consistent, when multiple sites of compression are suspected, or for patients with recurrent symptoms. Semmes–Weinstein pressure threshold tests are very valuable in confirming diagnosis and monitoring response to surgical intervention.

Amputation deformity Occasionally revision amputation is necessary to address an unstable soft tissue envelope, heterotopic ossification in the stump, or neuroma formation causing excessive paresthesias or dysthesias. Surgical principles include shortening the central bone or covering the distal portion of the amputation with vascularized tissue. Distraction osteogenesis has been reported but is rarely indicated and remains controversial.33 Thumb length can be preserved using an innervated kite flap from the dorsum of the index finger, or a groin flap to provide bulk and a larger surface area. Maximizing forearm length for a prosthesis or retaining the elbow may require free tissue transfer.

Thumb loss Because the thumb represents at least 40% of the function of the hand, extreme measures are employed to maximize thumb length, restore innervation, and retain range of motion. For patients who had a thumb amputation, options include pollicization of the index finger or toe-to-thumb

transfer.34 If patients do not want to sacrifice a normal toe or do not have an favorable recipient site (severe scarring with no inflow or outflow, absent median nerve, loss of flexor tendons), an alternative is a prosthetic thumb. An artificial thumb can be quite stable and can be fashioned to assist with opposition of the remaining fingers.

Elbow dysfunction Patients with thermal injury to the upper extremity may develop significant problems with elbow function that include flexion contractures of the antecubital fossa, cubital tunnel syndrome, lateral epicondylitis, and heterotopic ossification. All of these conditions may be present in isolation or in combination. The surgical management of heterotopic ossification begins with appropriate imaging with plain films and CT scans to identify areas of ossification that need to be excised. Unless the patient has motor loss from ulnar nerve compression, we wait at least 6 months from the time of injury to proceed. Operative intervention includes release of soft tissue contractures, resection of all abnormal bone deposits until full passive range of motion is restored, anterior transposition of the ulnar nerve to a submuscular or subfascial plane, and consideration of coverage with vascularized tissue.

Axillary contractures Limitations of shoulder abduction and rotation due to anterior or posterior contractures dramatically affect the function of the upper extremity. Limited scars with adjacent unburned tissue are amenable to rearrangement with multiple flap z-plasties, but most axillary contractures require major release. Options for resurfacing include thick split grafts, thin split grafts over acellular dermal matrix (Alloderm; LifeCell Corporation, Branchburg, NJ), or fasciocutaneous flaps, but the recurrence rate is frustratingly high. We currently prefer a two-staged approach that involves the application of a bilaminate skin substitute (Integra; Integra Lifesciences Corporation, Plainsboro, NJ) with a subatmospheric sponge dressing (VAC device; Kinetic Concepts, Inc., San Antonio, TX), followed 1–2 weeks later by definitive skin grafting.

Pain Patients presenting with debilitating pain following burn injury to the hand may have a combination of neuropsychiatric and functional components that need to be addressed. For patients with chronic pain due to non-anatomic etiologies, we initiate a pharmacotherapeutic regimen that includes non-steroidal anti-inflammatory drugs, antidepressants, anti-seizure agents, topical analgesics, and weaning off narcotics. However, the surgeon must also search for anatomic etiologies that can be corrected: nerve compression syndromes, neuroma formation, basilar thumb arthritis, and stenosing tenosynovitis.


REHABILITATION Once secondary and tertiary reconstructions have been completed, the patient continues with the process of rehabilitation. Occupational therapy represents the keystone for this endeavor. Patients must undergo a rigorous, individualized, and rationally designed protocol that maintains and optimizes the gains achieved by surgery. This includes active and passive range of motion exercises, strengthening, conditioning, sensory re-education, and fine-motor retraining. Skin care involves the indefinite use of sunscreen and moisturizing agents. Scar management remains important and is facilitated by deep massage, ultrasound, paraffin, and convective heat dry whirlpool. For patients with hypertrophic scars, options include silicone sheeting, steroid tape, or intralesional steroid injections. Finally, all patients must use compressive garments for years to mitigate the effects of chronic edema and persistent alterations in lymphatic drainage. Another important component of the rehabilitative process is the management of neuropsychiatric problems observed after burn injury. In addition to the functional hand problems that may compromise recovery, patients may present with chronic pain, post-traumatic stress disorder, affective illness, memory loss, personality changes, altered body image, and sexual dysfunction. Critical input from healthcare providers in physical medicine, anesthesia, neurology, psychiatry, and even alternative medicine (acupuncture, hypnosis) may alleviate some of this dysfunction.

REINTEGRATION Management of the thermally injured hand is not complete until patients return to their previous level of function or have at least reached their potential for recovery. This can be defined by resuming activities of daily living and by rejoining the workforce as a productive member of society. A rehabilitation counselor is essential for coordinating and facilitating this process of reintegration into society. Because the majority of hand burns in our practice are work related, most patients have access to resources that will aid in their transition back to employment. After completing reconstruction and nearing the conclusion of occupational therapy, we obtain a functional capacity evaluation (FCE) to determine what patients can do and what they can tolerate. We often combine the FCE with an assessment by vocational rehabilitation (VR), job retraining, and a site visit by the rehabilitation counselor who confirms that the new job description matches patient restrictions. Following a 3-month work trial, the patient receives a final impairment rating based on the AMA Guidelines for the Evaluation of Permanent Impairment (5th edition).35 This pathway from injury to recovery typically takes 1–2 years to complete. Although patients with hand burns may not require additional surgical care, the burn team follows these individuals indefinitely to ensure

that rehabilitative goals are maintained and that potential recovery is fulfilled. Supported in part by the Ethel F. and James A. Valone Distinguished Professorship in Plastic Surgery.

REFERENCES 1. Logsetty S, Heimbach DM. Modern techniques for wound coverage of the thermally injured upper extremity. Hand Clin 2000; 16: 205–214. 2. McCauley RL. Reconstruction of the pediatric burned hand. Hand Clin 2000; 16: 249–259. 3. Tredget EE. Management of the acutely burned upper extremity. Hand Clin 2000; 16: 187–203. 4. Greenhalgh DG. Management of acute burn injuries of the upper extremity in the pediatric population. Hand Clin 2000; 16: 175–186. 5. Salisbury RE. Reconstruction of the burned hand. Clin Plast Surg 2000; 27: 65–69. 6. Luce EA. The acute and subacute management of the burned hand. Clin Plast Surg 2000; 27: 49–63. 7. Kidd M, Hultman CS, Van Aalst JA, et al. Contemporary management of electrical injuries: Resuscitation, reconstruction, rehabilitation. Ann Plast Surg 2007; 58: 273–278. 8. Anzarut A, Chen M, Shankowsky H, Tredget EE. Quality-of-life and outcome predictors following massive burn injury. Plast Reconstruct Surg 2005; 116: 791–797. 9. Peterson SL, Moore EE. The integral role of the plastic surgeon at a level I trauma center. Plast Reconstruct Surg 2003; 112: 1371–1375. 10. Dantzer E, Queruel P, Salinier L, et al. Dermal regeneration template for deep hand burns: clinical utility for both early grafting and reconstructive surgery. Br J Plast Surg 2003; 56: 764–774. 11. Rue LW 3rd, Cioffi WG, McManus WF, Pruitt BA Jr. Wound closure and outcome in extensively burned patients treated with cultured autologous keratinocytes. J Trauma 1993; 34: 662–667. 12. Wu LC, Gottlieb LJ. Glabrous dermal grafting: a 12-year experience with the functional and aesthetic restoration of palmar and plantar skin defects. Plast Reconstruct Surg 2005; 116: 1679–1685. 13. Baruchin AM, Scharf S, Baruchin O, Yoffe B. Resurfacing of fingertip following deep burns: the hypothenar skin graft. Burns 2005; 31: 243–244. 14. Bunyan AR, Mathur BS. Medium thickness plantar skin graft for the management of digital and palmar flexion contractures. Burns 2000; 26: 575–578. 15. Ulkur E, Acikel C, Eren F, Celikoz B. Use of dorsal ulnar neurocutaneous island flap in the treatment of chronic postburn palmar contractures. Burns 2005; 31: 99–104. 16. Ege A, Tuncay I, Ercetin O. Posterior interosseous artery flap in traumatic hand injuries. Arch Orthop Trauma Surg 2003; 123: 323–326. 17. Yongwei P, Jianing W, Junhui Z, et al. The abdominal flap using scarred skin in the treatment of postburn hand deformities of severe burn patients. J Hand Surg [Am] 2004; 29: 209–215. 18. Tan O, Ergen D, Bayindir O. Winged groin flap for web space reconstruction. Burns 2006; 32: 660–661. 19. Sauerbier M, Ofer N, Germann G, Baumeister S. Microvascular reconstruction in burn and electrical burn injuries of the severely traumatized upper extremity. Plast Reconstruct Surg 2007; 119: 605–615. 20. Pan CH, Chuang SS, Yang JY. Thirty-eight free fasciocutaneous flap transfers in acute burned-hand injuries. Burns 2007; 33: 230–235. 21. Adani R, Tarallo L, Marcoccio I, Fregni U. First web-space reconstruction by the anterolateral thigh flap. J Hand Surg [Am] 2006; 31: 640–646. 22. Hasegawa H, Okazaki M, Sasaki K. Restoration of thumb abduction damaged by electrical burn using the free dorsalis pedis flap with the extensor hallucis brevis tendon. J Reconstruct Microsurg 2006; 22: 33–36.

330 Hand and Upper Extremity Reconstruction 23. Adani R, Tarallo L, Marcoccio I, et al. Hand reconstruction using the thin anterolateral thigh flap. Plast Reconstruct Surg 2005; 116: 467–473. 24. Topalan M, Ozden BC, Aydin A, Erer M. Use of free serratus anterior muscle slips for the reconstruction of dorsal-side defects of the hand resulting from hot press injury. J Burn Care Rehab 2004; 25: 346–348. 25. Tsai FC, Yang JY, Mardini S, et al. Free split-cutaneous perforator flaps procured using a three-dimensional harvest technique for the reconstruction of postburn contracture defects. Plast Reconstruct Surg 2004; 113: 185–193. 26. Woo SH, Seul JH. Optimizing the correction of severe postburn hand deformities by using aggressive contracture releases and fasciocutaneous free-tissue transfers. Plast Reconstruct Surg 2001; 107: 1–8. 27. Takeuchi M, Nozaki M, Sasaki K, et al. Microsurgical reconstruction of the thermally injured upper extremity. Hand Clin 2000; 16: 261–269. 28. Eski M, Nisanci M, Sengezer M. Correction of thumb deformities after burn: versatility of first dorsal metacarpal artery flap. Burns 2007; 33: 65–71.

29. Groenevelt F, Schoorl R. Reconstructive surgery of the post-burn boutonnière deformity. J Hand Surg [Br] 1986; 11: 23–30. 30. Donelan MB, Garcia JA. Nailfold reconstruction for correction of burn fingernail deformity. Plast Reconstruct Surg 2006; 117: 2303–2308. 31. Tan O, Atik B, Ergen D. Versatile use of the VM-plasty for reconstruction of the web space. Ann Plast Surg 2005; 55: 623–628. 32. Hultman CS, Teotia S, Calvert C, et al. STARplasty for reconstruction of the burned web space: introduction of an alternative technique for the correction of dorsal neosyndactyly. Ann Plast Surg 2005; 54: 281–287. 33. Ilhami K, Safak O, Orhan G. Specifically designed external fixators in treatment of complex postburn hand contractures. Burns 2003; 29: 609–612. 34. Williamson JS, Manktelow RT, Kelly L, et al. Toe-to-finger transfer for post-traumatic reconstruction of the fingerless hand. Can J Surg 2001; 44: 275–283.

INDEX Note: APL = abductor pollicis longus; CMC = carpometacarpal; DIP = distal interphalangeal; ECTR = endoscopic carpal tunnel release; IVRA = intravenous regional anesthesia; MCP = metacarpophalangeal; PIP = proximal interphalangeal; SLAC = scapholunate advanced collapse; SLIL = scapholunate interosseous ligament; STT = scaphotrapeziotrapezoid; TFCC = triangular fibrocartilage complex; UCL = ulnar collateral ligament

A abductor digiti quinti (ADQ) transfer, 199, 201, 203, 312 abductor pollicis longus (APL) tendon anatomy, 47 repair, 52, 58 suspension arthroplasty, 167–70 transfers radial nerve palsy, 196, 199 ulnar nerve palsy, 203, 204, 206 abscesses, subcutaneous, 210, 211, 215–16 Acutrac screw, 151, 153 adductor pollicis burned hands, 327 ulnar nerve palsy, 201, 203 adipofascial turnover flaps, 322, 324 advancement flaps, 277, 278 Agee method, ECTR, 259–60, 262 alkalization, local anesthetics, 3 Allen’s test, 269 amputation (surgical), 89–99 burned hands, 322, 327, 328 contraindications, 89 in the digit, 91, 92–5 fingertip, 91–2 indications, 89 pain relief, 99 preoperative considerations, 89–91 ray, 91, 95–9, 322 amputation (traumatic) replantation, 101–18 arterial anastomoses, 106, 108, 109–15 heterotopic, 118 ischaemia time, 102, 106 lesion types, 101–2 nerve repair, 106, 108, 116, 118 non-replantable fingers, 118 patient selection, 101–2 preoperative preparation, 102–6 proximal stump preparation, 106–7 skeletal fixation, 107–8 skin closure, 118 tendon sutures, 108–9 thumb, 101, 102, 103, 106–7, 108, 112–15, 116–17, 118, 277 transportation of amputated part, 102, 106

traumatic mechanisms, 102 vein repair, 106, 115–18 thumb reconstruction see thumb, reconstruction analgesia, finger amputation, 99 anconeus epitrochlearis, 266 Andre-Thomas sign, 204 anesthesia, 1–17 intravenous regional, 1, 3, 4, 5–6, 16 local anesthetic pharmacology, 2–3, 16 nerve blocks, 2, 4–17 surgical amputation, 91 anterior interosseous nerve syndrome (AINS), 263–5 antibiotics burned hands, 321 finger infections, 209, 210 anxiolysis, 1 arcade of Struthers, 266 arterial anastomoses replantation surgery, 106, 108, 109–15 thumb reconstruction, 284, 286, 290–1 arthrodesis, 149–60 or arthroplasty, 163, 164, 167 Dupuytren’s contracture, 223 fixation methods, 150–3, 160 joint surface preparation, 149–50, 151, 155 perilunate dislocations, 142 position, 149, 160 preoperative considerations, 149–50, 164 replantation surgery, 108 scapholunate instability, 146 arthrography perilunate dislocations, 140–1 scapholunate instability, 143 TFCC injuries, 124–5, 127 arthroplasty, 163–81 or arthrodesis, 164, 167 metacarpophalangeal joint, 164, 166, 170–7 proximal interphalangeal joint, 164–5, 166, 177–80 techniques, 164–6 thumb CMC, 164–5, 166–70 arthroscopy, TFCC repair, 121, 126–32 axillary contractures, 329 axonotmesis, 245, 246

B Bier’s block (IVRA), 1, 3, 4, 5–6, 16 bifid thumb (preaxial polydactyly), 306–8, 309 bone anchor technique, UCL repair, 83–4, 85 bone grafts arthrodesis, 153, 154, 155 scaphoid fractures, 137–8, 139 thumb reconstruction, 280 bone scintigraphy perilunate dislocations, 141 scaphoid fractures, 135 bone stapler, arthrodesis, 152, 153, 155 bone tunnel technique, UCL repair, 85–6, 87 bouquet pinning, 67, 68 boutonnière deformity after extensor tendon injury, 55, 56 burned hands, 325 MCP arthroplasty, 171 PIP arthroplasty, 177 rheumatoid arthritis leading to, 164, 165, 171 brachial plexus anatomy, 245–6, 247 brachial plexus injuries (BPI), 245–53 classification, 247 complications of surgery, 252–3 contraindications for surgery, 247 delayed presentation, 252 indications for surgery, 247 MABC nerve grafts, 235 nerve transfers, 237, 251–2 operative approach, 237, 248–52 postoperative care, 253 preoperative considerations, 247–8 surgical management algorithm, 247, 248 brachial plexus neuritis, 263, 264 brachioradialis, high median nerve palsy, 201, 203 Brand transfer, ulnar nerve palsy, 204, 205–6 Buck–Gramcko flap, pollicization, 315 Bunnell opposition transfer, 200 burned hands, 319–29 reconstruction, 322–9 amputation deformity, 328 axillary contractures, 329

331

332 Index boutonnière deformity, 325 claw hand, 326 elbow dysfunction, 328–9 finger contractures, 326 mallet finger, 325–6 nail-plate deformities, 327–8 nerve compression syndromes, 238 pain, 329 palmar contractures, 326 stiffness, 322 swan-neck deformity, 322–4 tension adhesions, 324 thumb loss, 328 web space deformities, 327, 328 rehabilitation, 329 reintegration, 329 resurfacing phase, 321–2 amputation, 322 excision, 321 flaps, 322 grafting, 322 temporary coverage, 321–2 resuscitation phase, 319–21 damage control, 320–1 mechanism of injury, 319 occupational therapy, 321 restoration of perfusion, 319–20 systemic issues, 321 wound care, 321 wound characteristics, 319

C Camitz opposition transfer, 199, 200–1, 202 capitate, four-corner fusion, 146, 156–7 carpal tunnel syndrome, 256–62, 328 anatomy, 256 anesthesia, 15, 17 electrodiagnostic studies, 257 endoscopic release, 259–62 history, 257 non-operative management, 257 open release, 257–9, 262 pathophysiology, 256 physical examination, 257 postoperative care, 259, 260 postoperative complications, 259, 260–2 surgical contraindications, 257, 259 surgical indications, 257, 259 carpectomy, SLAC wrist, 146, 147 carpometacarpal (CMC) joint arthrodesis, 149, 152, 155, 164, 167 arthroplasty, 164–5, 166–70 dislocations/fracture-dislocations, 62, 64– 5, 66 hemihamate arthroplasty, 75 osteoarthritis, 163, 166–7 carpus SLAC wrist carpectomy, 146, 147 ulnocarpal impaction syndrome, 128 cellulitis, 210, 211 central slip anatomy, 48–9 central slip injuries, 53, 55, 56, 325 central slip test (Elson’s test), 53 chevron osteotomy, arthrodesis, 150, 151 children burned hands, 322, 326 congenital hand procedures, 301–18

digital amputation (surgical), 89 extensor tendon injuries, 54, 55 replantation, 102, 103, 104 thumb reconstruction, 277, 281, 287 chondromalacia, TFCC injury, 126, 128 claw hand, burn injuries, 326 Clostridia infections, 216 collateral recess pinning metacarpal base fractures, 66 metacarpal shaft fractures, 62–3 compartment syndrome burned hands, 320 metacarpal shaft fractures, 61 compressive neuropathies see nerve compression syndromes computed tomography (CT) scans perilunate dislocations, 141 scaphoid fractures, 135 scaphoid nonunion, 136 TFCC injuries, 124 congenital hand procedures, 301–18 hypoplastic thumb, 312–18 postaxial polydactyly, 305–6 preaxial polydactyly, 306–8, 309 radial dysplasia, 301, 308–12 syndactyly, 301–5 cross-finger flap, thumb reconstruction, 277, 278 cross-side finger flap, thumb reconstruction, 277, 278 crossed K-wire fixation arthrodesis, 150–1, 154 metacarpal neck fractures, 67 phalangeal shaft fractures, 69, 71 CT scans see computed tomography (CT) scans cup and cone preparation, arthrodesis, 150, 151, 155

D Darrach procedure, 188–91 degloved skin, replantation, 102, 107, 111–12 dermofasciectomy, Dupuytren’s contracture, 226 digital artery, replantation surgery, 112–15 digital nerve blocks, 2, 11–15, 16, 17 distal interphalangeal (DIP) joint arthrodesis, 149, 150, 153–4, 164 arthroplasty, 164, 166 burned hands, 325–6 Dupuytren’s contracture, 221, 222, 227 extensor tendon anatomy, 49 extensor tendon injuries, 50, 53–5, 56, 325–6 flexor tendon injuries, 30, 32, 33–4, 35, 36 ganglion cysts, 23 osteoarthritis, 163, 166 rheumatoid arthritis, 163–4 septic arthritis, 215 surgical amputation at, 92, 94 traumatic amputation at, 108, 113, 115 distal radioulnar joint (DRUJ) piano key maneuver, 124

surgical procedures for, 183, 188–91 TFCC repair, 123, 124, 125, 127, 128, 130 distal radius fractures TFCC tears, 123, 124 volar plate fixation, 183–8 dorsal island flap, thumb reconstruction, 277, 279 dorsalis pedis flap, thumb reconstruction, 278–80, 291 dorsolateral island flap, thumb reconstruction, 277, 278 Doyle classification, mallet finger, 54–5 duplicated thumb (preaxial polydactyly), 306–8, 309 Dupuytren’s disease and contracture, 219–30 anatomy, 220–1 cause, 219–20 complications, 228–9 contraindications for surgery, 221–2 genetics, 219 histology, 219 indications for surgery, 221–2 nomenclature, 219 non-surgical treatment, 223 pathology, 220–1 postoperative care, 230 preoperative considerations, 223–4 surgical management, 224–30 Durkan’s test, 256, 257, 262

E Eaton classification, CMC joint disease, 166–7 Eikenella corrodens, 209, 216 elbow dysfunction, thermal injury, 328–9 electrical burns, 319–20, 321 amputation, 322, 327 flaps, 322, 323 electrodiagnostic studies (EDS) brachial plexus injuries, 248, 251 nerve compression syndromes, 256 anterior interosseous nerve, 264 burned hands, 328 carpal tunnel, 257 distal ulnar neuropathy, 269 pronator syndrome, 262–3 proximal ulnar neuropathy, 267 radial tunnel, 272 superficial radial nerve entrapment, 274 upper arm radial neuropathy, 271 endoscopic carpal tunnel release (ECTR), 259–62 epinephrine, as local anesthetic additive, 2, 16 epineurial sutures, nerve repair, 233–4 eponychium anatomy, 20 burned hands, 327–8 deformities, 22–3 infections, 214 extensor carpi radialis brevis (ECRB) tendon anatomy, 47, 49 injury assessment, 52

Index 333 transfers radial nerve palsy, 196, 197, 199 ulnar nerve palsy, 201, 203, 204, 205 extensor carpi radialis longus (ECRL) tendon anatomy, 47, 49 chronic scapholunate instability, 143 injury assessment, 52 thumb CMC arthroplasty, 168–9 transfers, 143, 196, 199 extensor carpi ulnaris (ECU) tendon anatomy, 47, 49 injuries assessment, 52 with TFCC injuries, 123, 124, 125 transfers, 196, 199 extensor digiti minimi (EDM) tendon, 47, 196 extensor digitorum communis (EDC) tendon anatomy, 47, 48, 49 injury assessment, 50, 52 injury repair, 56, 57 transfers, 196, 197, 198, 199 extensor indicis proprius (EIP) tendon anatomy, 47, 49 injury assessment, 51 transfers high median nerve palsy, 201, 203 low median nerve palsy, 199, 201 radial nerve palsy, 196, 198, 199 extensor pollicis brevis (EPB) tendon anatomy, 47 injury repair, 58 thumb CMC arthroplasty, 168, 169 transfers, 196, 199 extensor pollicis longus (EPL) tendon anatomy, 47, 49 injury assessment, 51 injury repair, 58 thumb CMC arthroplasty, 167, 168 transfers, 196, 197, 198, 199 extensor retinaculum injuries, 57, 58 extensor tendons, 47–58 anatomy, 47–9 finger amputation (surgical), 91, 92 injuries assessment, 49–50, 51–3 burns, 322–4, 325–6 complications, 58 rehabilitation, 58 suture technique, 50, 53, 54 treatment, 50, 53–8 zones, 49, 50 innervation sequence, 49 preaxial polydactyly, 306–7 replantation surgery, 108, 109 transfers chronic scapholunate instability, 143 median nerve palsy, 199, 201, 203 radial nerve palsy, 195–6, 197, 198, 199 ulnar nerve palsy, 201, 203, 204, 205 external fixators arthrodesis, 152 phalangeal fractures, 74–5 PIP joint arthroplasty, 180

F fascicular sutures, nerve repair, 233–4 fasciectomy, Dupuytren’s contracture, 223, 226 fasciotomy burned hands, 320, 327 Dupuytren’s contracture, 223 felons, 210, 214–15 field blocks, 15, 17 finger amputation (surgical), 89 burned hands, 322 contraindications, 89 indications, 89 operative approach, 91–9 postoperative management, 99 preoperative considerations, 89–91, 92–3 amputation (traumatic) replantation, 102, 104, 106–10, 112–14, 117, 118 thumb reconstruction, 295, 296–7 anterior interosseous nerve syndrome, 264 arthrodesis, 149, 150, 151–2, 153–4, 164 arthroplasty, 163, 164–5, 166, 170–80 boutonnière deformity, 55, 56, 164, 165, 171, 177, 325 burns see burned hands contractures, 326, 327 distal ulnar neuropathy, 269 Dupuytren’s contracture, 221, 222, 223, 224–30 infections see finger infections joints see distal interphalangeal (DIP) joint; metacarpophalangeal (MCP; MP) joint of finger; proximal interphalangeal (PIP) joint mallet, 53–5, 325–6 osteoarthritis, 163, 170, 178 phalangeal fractures see phalangeal fractures pollicization, 292, 295, 296–7, 313–18 polydactyly, 301, 305–8 posterior interosseous nerve entrapment, 273 proximal ulnar neuropathy, 266, 267 rheumatoid arthritis, 163–4, 165, 170, 171, 178 sensory nerve transfers, 241–2 superficial radial nerve entrapment, 273–4 swan-neck deformity, 55, 163, 164–5, 171, 178, 322–4 syndactyly, 301–5, 327 tendons see finger extensor tendons; finger flexor tendons finger extensor tendons anatomy, 47–9 finger amputation (surgical), 91, 92 injuries assessment, 49–50, 51–2, 53 burns, 322–4, 325–6 sutures, 50, 53, 54 treatment, 50, 53–7 replantation surgery, 108, 109

transfers high median nerve palsy, 201, 203 low median nerve palsy, 199, 201 radial nerve palsy, 195–9 finger flexor tendons, 29 anatomy, 29–30, 31 burned hands, 322–4 finger amputation (surgical), 91, 95 intrinsic healing, 29 purulent tenosynovitis, 211–14 replantation surgery, 108–9 transfers high median nerve palsy, 201, 203 low median nerve palsy, 199, 200, 201 radial nerve palsy, 196 ulnar nerve palsy, 203, 204, 206 zone 1 injuries, 29, 30–5, 36 zone 2 injuries, 35–9 zone 3 injuries, 43–4 zone 5 injuries, 44 finger infections, 209–17 complications, 216 contraindications for surgery, 209, 211 felons, 210, 214–15 indications for surgery, 209–11 paronychia, 210, 214–15 postoperative care, 216 preoperative considerations, 211 purulent flexor tenosynovitis, 211–14 septic arthritis, 210, 215 subcutaneous abscesses, 210, 211, 215–16 fingernail infections, 210, 214–15 fingernail preservation, 91, 92 fingernail reconstruction, 19–26 anatomy, 20 burned hands, 327–8 complications, 24–5 contraindications, 19 DIP joint ganglion cysts, 23 eponychial deformities, 22–3 exposure, 20 hyponychial deformities, 22–3 indications, 19 nail bed reconstruction, 21, 23–5, 26 nail bed repair, 20, 21–2, 23, 26 outcome optimization, 23–4 pincer nail reconstruction, 22, 25–6 postoperative care, 25–6 preoperative considerations, 19–20 thumb, 283, 284–6, 289 tourniquets, 20 fingertip amputation, 91–2 fingertip infections, 210, 211, 212, 214–15 flaps burned hands, 322, 323–6 Dupuytren’s contracture surgery, 224, 225, 228–9 finger amputation (surgical), 92, 94 hypoplastic thumb, 312, 313, 314, 315, 317 preaxial polydactyly, 306, 308 radial dysplasia, 309–12 replantation surgery, 118 syndactyly reconstruction, 301, 303, 304

334 Index thumb reconstruction, 277–84, 285–9, 291, 294, 295 zone 2 flexor tendon injuries, 35–6, 37 flexor carpi radialis (FCR) tendon thumb CMC arthroplasty, 168, 169–70 transfers chronic scapholunate instability, 143, 144 radial nerve palsy, 196–8, 199 flexor carpi ulnaris (FCU) tendon, 196, 200, 201 flexor digitorum profundus (FDP) tendon, 29 anterior interosseous nerve syndrome, 264 finger amputation (surgical), 91, 95 high median nerve palsy, 201, 203 replantation surgery, 108 two-stage tendon reconstruction, 39–40, 41 zone 1 injuries, 30–5, 36 zone 2 injuries, 35, 36–7 zone 3 injuries, 44 zone 5 injuries, 44 flexor digitorum superficialis (FDS) tendon, 29 transfers low median nerve palsy, 199, 200 radial nerve palsy, 196 ulnar nerve palsy, 201, 203, 204, 206 two-stage tendon reconstruction, 40 zone 1 injuries, 32, 35, 36 zone 2 injuries, 35, 36–7 zone 3 injuries, 44 zone 5 injuries, 44 flexor pollicis longus (FPL) tendon anatomy, 30 anterior interosseous nerve syndrome, 263, 264 injury repair, 43 purulent tenosynovitis, 213 transfers high median nerve palsy, 201, 203 radial nerve palsy, 196, 199 ulnar nerve palsy, 201 flexor tendons, 29–46 anatomy, 29–30, 31 anterior interosseous nerve syndrome, 263, 264 burned hands, 322–4 fingertip amputation (surgical), 91, 95 intrinsic healing, 29 postoperative rupture, 35, 38 purulent tenosynovitis, 211–14 replantation surgery, 108–9 thumb CMC arthroplasty, 168, 169–70 transfers chronic scapholunate instability, 143, 144 high median nerve palsy, 201, 203 low median nerve palsy, 199, 200, 201 radial nerve palsy, 195, 196, 199 ulnar nerve palsy, 203, 204, 206 two-stage reconstruction, 39–43 zone 1 injury repair, 30–5, 36 zone 2 injury repair, 35–9 zone 3 injury repair, 43–4

zone 4 injury repair, 44 zone 5 injury repair, 44–5 flexor tenosynovitis, purulent, 211–14 fluoroscopic imaging distal radius fractures, 186, 187, 188 TFCC repair, 130 forearm amputations, replantation, 102, 105, 109 four-corner fusion, 146, 156–7 SLAC wrist, 146 fractures complications, 75–7 distal radius, 123, 124, 183–8 metacarpal, 61–8 phalangeal see phalangeal fractures scaphoid, 135–9 ulnar, 125, 127 Froment’s sign, 201, 203 functional capacity evaluation (FCE), burned hands, 329 fungal infections, burned hands, 321

G gamekeeper’s thumb, 79, 84–5 ganglion cysts, DIP joint, 23 general anesthesia, advantages, 2 Gilula’s lines, 140, 141, 143 gracilis muscle transfer, 252, 253 groin flap burned hands, 322, 326 thumb reconstruction, 294 Guyon’s canal compression, 259, 268–9, 271, 328

H hamate degenerative TFCC lesions, 128 four-corner fusion, 146, 156–7 headless bone screws metacarpal head fractures, 68 scaphoid fractures, 136, 137 hemihamate arthroplasty, 75, 77 Herbert screws, 150 herpetic whitlows, 211, 212 Horner’s syndrome, 251 hot-press burns, 319, 321 Houston’s tabletop test, 222 Huber transfer, 201, 203, 312 humpback deformity, 135, 136, 137 hyponychium anatomy, 20 deformities, 22–3 hypoplastic thumb, 312–18

I interosseous artery, TFCC, 121 interosseous muscles extensor mechanism, 47 ray amputation, 96–7 interosseous wiring, arthrodesis, 150, 151, 152 interphalangeal (IP) joint see distal interphalangeal (DIP) joint; proximal interphalangeal (PIP) joint intramedullary nails (IMs), 64 intravenous regional anesthesia (IVRA; Bier’s block), 1, 3, 4, 5–6, 16

ischaemia time, replantation, 102, 106 island flaps, 277, 278, 279, 280, 282–3, 295, 296–7

J Jahss maneuver, 66–7 Jeanne’s sign, 201, 267 juncturae tendinum extensor tendon anatomy, 48 extensor tendon injuries, 50, 51, 57

K K-wiring arthrodesis, 150–1, 154, 155, 156, 158, 159, 160 metacarpal base fractures, 65, 66 metacarpal neck fractures, 67, 68 metacarpal shaft fractures, 62, 64 phalangeal head fractures, 72 phalangeal shaft fractures, 69, 71, 72 ray amputation, 97, 99 replantation surgery, 107–8, 113, 115 UCL repair, 86 Kanavel’s signs, 210 kite flap burned hands, 322, 323 thumb reconstruction, 277, 278, 279

L lag screws metacarpal base fractures, 65 metacarpal shaft fractures, 63–4 phalangeal head fractures, 72, 74 phalangeal shaft fractures, 72 lateral antebrachial cutaneous (LABC) nerve, 235, 236, 237 lidocaine, 2, 3 ligament injuries extensor retinaculum, 57, 58 perilunate dislocations, 139–42 scapholunate instability, 142, 143, 144 TFCC see triangular fibrocartilage complex (TFCC) repair ulnar collateral ligament of thumb, 79–87 local anesthetics epinephrine with, 2, 16 IVRA technique, 4 local infiltration, 15–17 pharmacology, 2–3, 16 use in nerve blocks see nerve blocks lumbrical muscles, 47–8 lunate dislocation, 139, 140, 141 four-corner fusion, 146, 156–7 radiolunate fusion, 157, 158 scapholunate dissociation, 139, 140, 142–7 lunocapitate dissociation, 139, 140 lunotriquetral joint dissociation, 139, 140 TFCC repair, 123–4, 130, 132

M magnetic resonance imaging (MRI) perilunate dislocations, 141 scaphoid fractures, 135, 136 scapholunate instability, 143

Index 335 TFCC injuries, 124–5 mallet finger burned hands, 325–6 management, 53–5 mallet injuries of thumb, 58 McCash operation, 225 medial antebrachial cutaneous (MABC) nerve graft, 235–6 median nerve compression syndromes anterior interosseous nerve, 263–5 carpal tunnel, 15, 17, 256–62, 328 pronator syndrome, 262–3 transfer from radial nerve, 238–9, 240 transfer from ulnar nerve, 238, 241–2 transfer to radial nerve, 239–41 see also median nerve injuries median nerve block at wrist, 8–10, 11, 13 in mid-forearm, 4–7, 9 median nerve injuries reconstruction nerve grafts, 235–6 nerve transfers, 238–9, 240, 242–3 tendon transfers, 199–201, 202–3 with zone 5 flexor tendon injuries, 30, 44–5 metacarpals fractures, 61–8 base, 64–6 complications, 75–7 head, 68 neck, 66–8 shaft, 61–4 pollicization, 313, 317 ray amputation, 96, 97, 98 replantation, 102, 107, 114 metacarpophalangeal (MCP; MP) joint of finger arthrodesis, 149, 150, 151, 152, 154, 164 arthroplasty, 164, 166, 170–7 burned hands, 324, 326 Dupuytren’s contracture, 221, 222, 223, 224, 225, 230 extensor tendon anatomy, 47, 48, 49 extensor tendon repair, 50, 52, 56–7 osteoarthritis, 163, 170 replantation surgery, 108 rheumatoid arthritis, 163, 164, 170, 171 surgical amputation through, 91, 93 ulnar nerve palsy, 201, 203, 204 metacarpophalangeal (MCP; MP) joint of thumb arthrodesis, 149, 153, 154–5, 164, 167, 171 arthroplasty, 164–5, 167, 171 burned hands, 324, 326 extensor tendon anatomy, 47 extensor tendon repair, 58 hyperextension deformity, 167 hypoplasia, 312–13, 315 osteoarthritis, 163 replantation surgery, 108 rheumatoid arthritis, 163, 164 UCL injuries, 79, 80, 81, 82, 84, 85 whole great toe transfer, 285, 287–90

midazolam, 1 MRI see magnetic resonance imaging MRSA infections, 209 mycobacterial infections, 209, 216

N nail see fingernail nerve action potentials (NAPs) anterior interosseous nerve syndrome, 264 brachial plexus injuries, 251 nerve blocks contraindications, 2 digital, 2, 11–15, 16, 17 local anesthetic pharmacology, 2, 3 in mid-forearm, 4, 16 median nerve, 4–7, 9 radial nerve, 7–8, 10 ulnar nerve, 7, 9 ultrasound guidance, 4, 6, 7, 8–9, 16 at wrist, 8–11, 13, 16 median nerve, 8–10, 11, 13 radial nerve, 11, 13 ulnar nerve, 10–11, 12, 13 nerve compression syndromes, 255–75 anterior interosseous nerve, 263–5 burned hands, 328 carpal tunnel, 15, 17, 256–62, 328 distal ulnar neuropathy, 268–70, 271, 328 electrodiagnostic studies, 256 nerve anatomy, 255 nerve physiology, 255 posterior interosseous nerve, 272–3 pronator syndrome, 262–3 proximal ulnar neuropathy, 266–8 radial tunnel syndrome, 272 superficial radial nerve, 273–5 upper arm radial neuropathies, 270–2 nerve conduction studies (NCS), 256 anterior interosseous nerve syndrome, 264 brachial plexus injuries, 251 burned hands, 328 carpal tunnel syndrome, 257 distal ulnar neuropathy, 269 pronator syndrome, 262–3 radial tunnel syndrome, 272 superficial radial nerve entrapment, 274 upper arm radial neuropathy, 271 nerve conduits, 236–7 nerve defects, 235 nerve gaps, 235, 236, 237 nerve grafting, 234–6, 251 nerve injuries extensor tendon system anatomy, 49 extensor tendon system repair, 57, 58 physiology of regeneration, 245 reconstruction, 233–42 brachial plexus, 235, 237, 245–53 direct repair, 233–4, 251 nerve conduits, 236–7 nerve grafting, 234–6, 251 nerve transfers, 233, 237–42, 251–2 replantation surgery, 106, 108, 116, 118 Seddon classification, 245, 246 tendon transfers, 195–206 with thumb UCL repair, 84, 87

with zone 5 flexor tendon injuries, 30, 44–5 nerve management, finger amputation (surgical), 95, 96–7 nerve root avulsion, brachial plexus injuries, 250–1 nerve transfers, 233, 237–42, 251–2 neurapraxia, 245, 246 neurolysis, brachial plexus injuries, 251 neurotization see nerve transfers neurotmesis, 245, 246 neurotoxicity, local anesthetics, 3 neurovascular island flap, thumb, 277, 278, 295, 296–7

O occupational therapy, burned hands, 321, 329 on-top-plasty, 295, 296–7 onychocutaneous flaps, 283, 284–6 open reduction with internal fixation (ORIF) metacarpal neck fractures, 67–8 metacarpal shaft fractures, 63, 64 phalangeal shaft fractures, 69, 71, 72 PIP fracture-dislocations, 75 opposition, thumb burned hands, 328 hypoplasia, 312–13 nerve transfers, 238 tendon transfers, 199–201, 203 Osborne’s ligament, 266 osteoarthritis (OA) arthroplasty, 163, 166–7, 170, 178 SLAC wrist, 146, 147 osteocutaneous flap, thumb, 280–3, 285, 286

P pain relief burned hands, 329 finger amputation (surgical), 99 palmar advancement flap, thumb, 277, 278 palmar contractures, burned hands, 326 palmar cutaneous nerve block, 10, 11 palmar fascia, Dupuytren’s disease, 220–1, 223, 224 palmaris longus tendon transfer Camitz opposition transfer, 199, 200–1, 202 radial nerve palsy, 196–7, 198, 199 two-stage flexor tendon reconstruction, 40, 41, 42 UCL repair, 85, 86, 87 Palmer classification, TFCC injuries, 125–6 paronychia, 210, 214–15 Parsonage–Turner syndrome, 263, 264 Pasteurella multocida, 209, 216 perilunate dislocations, 139–42 perionychium burned hands, 327–8 fingernail reconstruction, 19–26 infections, 210, 211, 212, 214–15 surgical amputation, 91–2 thumb reconstruction, 283, 284–6, 289 phalangeal fractures, 61, 69–77 complications, 75–7 extensor tendon injuries, 55 flexor tendon injuries, 30, 32–4

336 Index head, 72–5 with nail bed injuries, 19, 20 shaft, 69–72 thumb reconstruction, 280, 282–3 Phalen’s test, 256, 257, 262 piano key maneuver, 124 pincer nail reconstruction, 22, 25–6 plantaris tendon transfer, 204, 205–6 plate fixation arthrodesis, 152, 156, 158–9 distal radius fractures, 183–8 metacarpal fractures, 63, 67, 68 phalangeal fractures, 69, 71, 72 pollicization, 292, 295, 296–7 hypoplastic thumb, 313–18 polydactyly, 301 postaxial, 305–6 preaxial, 306–8, 309 posterior interosseous nerve (PIN) entrapment, 272–3 radial tunnel syndrome, 272, 273, 274 TFCC innervation, 121 upper arm radial neuropathy, 270 posterior interosseous osteocutaneous flap, 280–1 power pinch, 201, 203, 204, 206 preaxial polydactyly, 306–8, 309 pronation, nerve transfers for, 238, 239 pronator quadratus (PQ) anterior interosseous nerve syndrome, 263, 264 burned hands, 320 pronator syndrome, 262–3 pronator teres (PT) transfers, 196–8 proximal interphalangeal (PIP) joint arthrodesis, 150, 153, 154, 164, 223 arthroplasty, 164–5, 166, 177–80 burned hands, 324, 325, 326 Dupuytren’s contracture, 221, 222, 223, 224, 226–9, 230 extensor tendon anatomy, 49 extensor tendon injury assessment, 50, 53 extensor tendon injury repair, 55–6 fracture-dislocations, 72–7 osteoarthritis, 163, 178 phalangeal shaft fractures, 69 rheumatoid arthritis, 163–4, 178 septic arthritis, 215 ulnar nerve palsy, 201, 203 Pseudomonas infections, 209, 216 pullout sutures, UCL repair, 83, 84 pulp flap, thumb reconstruction, 277–8, 280–1 Pulvertaft weave, 194–5, 196 purulent flexor tenosynovitis, 211–14 pyrolytic carbon (pyrocarbon) implant arthroplasty, 165, 166, 170 MCP joint, 173–7 PIP joint, 177, 178–80

Q quadriga effect, 32, 33 quantitative sensory testing (QST), 256 anterior interosseous nerve syndrome, 264 distal ulnar neuropathy, 269

pronator syndrome, 263 superficial radial nerve entrapment, 274

R radial artery, replantation surgery, 108, 109, 112 radial artery forearm flap burned hands, 325 thumb reconstruction, 280, 282–3 radial dysplasia, 301, 308–12 radial nerve compression syndromes burned hands, 328 posterior interosseous nerve entrapment, 272–3 radial tunnel syndrome, 272 superficial radial nerve entrapment, 273–5 upper arm, 270–2 replantation surgery, 108 thumb CMC arthroplasty, 170 transfer from median nerve, 239–41 transfer to median nerve, 238–9, 240 see also radial nerve injuries radial nerve block at wrist, 11, 13 in mid-forearm, 7–8, 10 radial nerve injuries extensor tendon system anatomy, 49 nerve transfers, 239–41 reconstruction, 237 tendon transfers, 195–9 radial (preaxial) polydactyly, 306–8, 309 radial tunnel syndrome, 272 radiocarpal joint, 183 radiolunate fusion, 157, 158 radioulnar joint, distal see distal radioulnar joint radius distal fractures TFCC tears, 123, 124 volar plate fixation, 183–8 radiolunate fusion, 157, 158 TFCC biomechanics, 121–3 TFCC repair diagnostic imaging, 124 injury classification, 125–6 patient history, 123, 124 type ID lesions, 128 ray amputation, 91, 95–9, 322 regional anesthesia, 1–17 intravenous, 1, 3, 4, 5–6, 16 local anesthetic pharmacology, 2–3, 16 nerve blocks, 2, 4–17 surgical amputation, 91 replantation techniques, 101–18 arterial anastomoses, 106, 108, 109–15 heterotopic, 118 ischaemia time, 102, 106 lesion types, 101–2 nerve repair, 106, 108, 116, 118 non-replantable fingers, 118 patient selection, 101–2 preoperative preparation, 102–6 proximal stump preparation, 106–7 skeletal fixation, 107–8

skin closure, 118 tendon sutures, 108–9 transportation of amputated part, 102, 106 traumatic mechanisms, 102 vein repair, 106, 115–18 resuscitation, hand burn patients, 319–21 reverse flow flap, burned hands, 322, 325 reversed island flap, thumb, 278 rheumatoid arthritis (RA), 163–4 arthroplasty, 167, 170, 171, 178 distal radioulnar joint, 188 wrist arthrodesis, 159–60 ring avulsion injury, 102, 107–10, 112–14, 117 ring sign perilunate dislocations, 140 scapholunate instability, 143 Rüsse bone graft, 137, 139

S Sauvé–Kapandji procedure, 188 scaphoid displacement test, 142 fractures, 135–9 nonunion, 135, 136, 145–6 scapholunate instability/dissociation, 139, 140, 142–7 shift test, 142 SLIL open reduction and reconstruction, 141–2 SLIL open reduction and repair, 141 STT fusion, 146, 156 scaphoid nonunion advanced collapse (SNAC) wrist, 136, 145, 156 scapholunate advanced collapse (SLAC) wrist, 146, 147, 156 scapholunate dissociation, 139, 140, 142–7 scapholunate interosseous ligament (SLIL) acute scapholunate dissociation, 143 open reduction and reconstruction, 141–2 open reduction and repair, 141 scaphotrapeziotrapezoid (STT) fusion, 146, 156 scar formation, metacarpal and phalangeal fractures, 75 scar management, burned hands, 329 scintigraphy perilunate dislocations, 141 scaphoid fractures, 135 screw fixation arthrodesis, 150, 151–2, 153, 155 metacarpal fractures, 63–4, 65, 68 phalangeal fractures, 72, 74 scaphoid fractures, 136, 137 sedation, preanesthetic, 1 Seddon classification, nerve injuries, 245, 246 Semmes–Weinstein testing (SWT), 256, 328 sensory nerve action potentials (SNAPs), 251 sensory nerve transfers, 241–2 septic arthritis, 210, 215 Serratia spp. infections, 209, 216

Index 337 silicone arthroplasty, 166 MCP joint (SMPA), 170, 171–3, 174, 175–6 PIP joint, 178, 180 thumb CMC arthritis, 167 silicone rods, flexor tendon reconstruction, 40–1 skier’s thumb, 79 skin flaps see flaps skin grafts axillary contractures, 329 burned hands, 322, 324, 325, 326, 327 Dupuytren’s contracture, 225, 226, 230 Slade procedure, scaphoid fractures, 136–7 somatosensory evoked potentials (SSEPs), 251 splints arthrodesis, 154, 155 Darrach procedure, 190 distal radius fractures, 188 Dupuytren’s contracture, 230 extensor tendon injuries, 55, 57, 58 MCP arthroplasty, 177 PIP arthroplasty, 180 ray amputation, 99 TFCC repair, 132 thumb CMC arthroplasty, 170 thumb UCL repair, 81–2, 83–4, 86, 87 split thumb (preaxial polydactyly), 306–8, 309 Sporothrix infections, 216 Staphylococcus aureus infections, 209 staple fixation, arthrodesis, 152, 153, 155 Starr transfer, 196–8 Stener lesion, 80, 81, 82, 84 stiffness, burned hands, 322 streptococcal infections, 209, 214 Struthers’ arcade, 266 subcutaneous abscesses, 210, 211, 215–16 superficial radial nerve (SRN) entrapment, 273–5 suppurative (purulent) tenosynovitis, 211–14 sural nerve graft, 235–6 suspension arthroplasty, thumb CMC, 167–70 suture anchors, thumb UCL injuries, 85, 86 sutures extensor tendon injuries, 50, 53, 54 flexor tendon injuries, 32–3, 34, 35, 36, 37–8 nerve repair, 233–4 replantation surgery, 109–10 surgical finger amputation, 97 UCL repair, 83, 84, 85, 86 swan-neck deformity burned hands, 322–4 chronic mallet deformity leading to, 55 MCP arthroplasty, 171 PIP arthroplasty, 178 rheumatoid arthritis leading to, 163, 164–5, 171 Swanson silicone implants, 166 syndactyly burned hands, 327 congenital, 301–5

T tendon(s) extensor tendon injury management, 47–58 finger amputation (surgical), 91, 92, 95 flexor tendon repair, 29–46 modified APL suspension arthroplasty, 167–70 replantation surgery, 108–9 transfers, 193–206 chronic scapholunate dissociation, 143, 144 contraindications, 193–4 decision-making principles, 193 donor muscle amplitude, 194, 196 donor muscle availability, 193 donor muscle strength, 193–4 indications, 193–4 line of pull, 194 median nerve palsy, 199–201, 202–3 operative techniques, 194–5, 196 preoperative considerations, 194 radial nerve palsy, 195–9 single function/synergy, 194 SLIL open reduction and reconstruction, 142 tendon harvest, 194–5 two-stage reconstruction, 40, 41, 42 UCL repair, 85, 86, 87 ulnar nerve palsy, 201–6 tenodermodesis, 55 tenodesis, ulnar nerve palsy, 201, 203 tenodesis test, extensor tendon, 53 tenolysis, 39 burned hands, 324 tenosynovitis, purulent flexor, 211–14 tension adhesions, burned hands, 324 tension band wiring, arthrodesis, 150, 151, 152 Terry Thomas sign, 140 thermal injury see burned hand Thompson suspension arthroplasty, 169 thumb amputation (surgical), 89, 90, 327, 328 amputation (traumatic) reconstruction see thumb, reconstruction replantation, 101, 102, 103, 106–7, 108, 112–15, 116–17, 118, 277 anterior interosseous nerve syndrome, 264 arthrodesis or arthroplasty, 164, 167, 171 fixation, 153, 155 position, 149, 150, 155 procedure, 154–5 staple fixation, 152, 155 arthroplasty, 164–5, 166–70, 171 bifid, 306–8, 309 burned hands, 327, 328 Dupuytren’s contracture, 221 extensor/abductor tendons anatomy, 47 preaxial polydactyly, 306–7 repair, 51, 52, 58 transfers, 195–6, 197, 199, 203, 204 flexor tendon system anatomy, 30

flexor tendon system repair, 43 hypoplasia, 312–18 opposition burned hands, 328 hypoplasia, 312–13 nerve transfers, 238 tendon transfers for, 199–201, 202–3 osteoarthritis, 163, 166–7 reconstruction, 277–98 burned hands, 328 defect classification, 277, 278 donor site problems, 291 hypoplasia, 312–18 objectives, 277 on-top-plasty, 295, 296–7 options, 281, 285, 298 partial great toe transfer, 281–9, 298 pollicization, 292, 295, 296–7, 313–18 preaxial polydactyly, 306–8, 309 second-toe transfer, 281, 285, 291–2, 294, 298 soft tissue defects, 278–80 soft tissue plus bone defects, 280–1, 282–5 toe-to-thumb reattachment, 290–1 trimmed great toe transfer, 287, 298 whole great toe transfer, 285, 287–91, 298 wraparound procedure, 285, 286–7, 292–3, 298 split, 306–8, 309 tendon transfers for opposition, 199–201, 202–3 radial nerve palsy, 195–6, 197, 199 ulnar nerve palsy, 201, 203, 204, 206 ulnar collateral ligament acute injury, 79–84 chronic injury, 79, 84–7 Tinel’s sign, 257, 262, 267, 269, 328 toe, thumb reconstruction, 277–98 transthecal digital nerve block, 13–15, 16, 17 transverse carpal ligament (TCL), 256, 257, 258, 259, 260–2 transverse K-wire pinning metacarpal base fractures, 65 metacarpal neck fractures, 67, 68 metacarpal shaft fractures, 62 transverse retinacular ligament (TRL), 49 trapeziectomy, 167–8, 170 trapezium, STT fusion, 146, 156 trapezoid, STT fusion, 146, 156 triangular fibrocartilage complex (TFCC) repair, 121–32 anatomy, 121 biomechanics, 121–3 complications, 131 diagnostic imaging, 124–5, 127 indications, 123 injury classification, 125–6 nerve supply, 121, 131 non-operative, 123 patient history, 123–4 postoperative care, 132 type IA lesions, 125, 126–7 type IB lesions, 125, 127

338 Index type IC lesions, 125, 127–8 type ID lesions, 125–6, 128 type II degenerative lesions, 126, 128– 31, 132 vascular supply, 121 triangular ligament, 49 triquetrum, four-corner fusion, 146, 156–7 see also lunotriquetral joint twisted-toe flap techniques, 287

nerve transfers, 238 tendon transfers, 201–6 with zone 5 flexor tendon injuries, 30, 45 ulnar (postaxial) polydactyly, 305–6 ulnocarpal impaction syndrome, 128 ultrasound-guided regional anesthesia, 4, 6, 7, 8–9, 16

U

vein grafts, 109, 111, 112, 115, 117 vein repair, 106, 115–18 Verdan zones, extensor tendon injury, 49, 50 vibrometry, 256 vincula system, 30, 32 volar plate arthroplasty (VPA), 75, 77 volar plate fixation, distal radius fractures, 183–8 volar V-Y advancement flap, thumb, 277

ulna fractures, 125, 127 impaction syndrome, 128 TFCC repair, 121–3, 124, 125, 127, 128–31 see also distal radioulnar joint ulnar artery replantation surgery, 108, 109, 112 TFCC vascular supply, 121 thrombosis, 269 ulnar artery forearm island flap, 280–1 ulnar collateral ligament (UCL) of thumb, 79–87 acute injury, 79–84 chronic injury, 79, 84–7 ulnar nerve compression syndromes burned hands, 328 distal, 268–70, 271 proximal, 266–8 replantation surgery, 108 TFCC innervation, 121 transfer to median nerve, 238, 241–2 see also ulnar nerve injuries ulnar nerve block at wrist, 10–11, 12, 13 in mid-forearm, 7, 9 ulnar nerve injuries nerve grafts, 235–6

V

W wafer procedure, TFCC repair, 128, 130–1 wallerian degeneration, 245 Wartenberg sign, 267 web space burned hands, 327, 328 hypoplastic thumb, 312, 314–15 sensory nerve transfers, 241–2 syndactyly reconstruction, 303, 304, 305 wraparound procedure, thumb reconstruction, 285, 286–7, 292– 3, 298 wrist anatomy, 121, 122 arthrodesis limited, 155–7 perilunate dislocations, 142 position, 149, 160

replantation surgery, 108 SLAC wrist, 146, 156 total, 157–60 median-to-radial nerve transfer, 240 nerve blocks at, 8–11, 12, 13, 16 perilunate dislocations, 139–42 posterior interosseous nerve entrapment, 273 scaphoid fractures, 135–9 scaphoid nonunion, 135, 136, 145–6 scapholunate instability, 142–7 superficial radial nerve entrapment, 273 tendon transfers radial nerve palsy, 195–9 ulnar nerve palsy, 204 TFCC repair, 121–32 traumatic amputation, replantation, 102, 109 ulnar-sided pain diagnosis, 121, 123 wrist blocks, 8–11, 12, 13, 16

X X-rays distal radius fractures, 184, 185 finger infections, 211 metacarpal base fractures, 64–5 metacarpal head fractures, 68 perilunate dislocations, 139–40 PIP fracture-dislocations, 73, 74 scaphoid fractures, 135 scapholunate instability, 142–3 TFCC injuries, 124 thumb UCL injuries, acute, 81

Z Z-plasties burned hands, 323, 327 hypoplastic thumb, 312, 314 syndactyly, 301, 303, 304

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