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									Note to user: To search for a chapter, go to “Edit”, “Find”, the “Chapter x”. Also may use this feature like an index. *This outline was produced by Steve K. Lee, M.D. for the fellows and residents of The NYU Hospital for Joint Diseases and is not to be re-distributed without the consent of Dr. Lee

ESSENTIALS OF GREEN’S OPERATIVE HAND SURGERY – 4th edition Steve K. Lee, M.D. (APM=Author’s Preferred Method)
CONTENTS – Chapters 1) General principles 2) Anesthesia 3) Amputations 4) Small joint arthrodesis 5) Intercarpal arthrodesis 6) Radiocarpal arthrodesis 7) Hand & wrist arthroplasty 8) Wrist arthroscopy: 1 9) Wrist arthroscopy: 2 10) Wrist arthroscopy: 3 11) Elbow arthroscopy: 1 12) Elbow arthroscopy: 2 13) CP 14) Stroke/BI 15) Congenital 16) Stiff joints 17) Dupuy 18) Volkman 19) Intrinsic contracture 20) Distraction lengthening 21) RSD 22) Elbow contracture 23) Tennis elbow 24) Compartment syndrome 25) MC and phalangeal fxs 26) Digit dislocations 27) Carpal fxs 28) Carpal instability 29) DRF 30) DRUJ 31) Acute infection 32) Chronic infection 33) Micro 34) Replants

35) 36) 37) 38) 39) 40) 41) 42) 43) 44) 45) 46) 47) 48) 49) 50) 51) 52) 53) 54) 55) 56) 57) 58) 59) 60) 61) 62) 63) 64) 65) 66) 67) 68) 69) 70) 71)

Flaps Free muscle transfer Vascularized bone graft Vascularized joint transfer Brachial plexus recon Toe(thumb transplant Toe(finger transplant Perionychium Nerve repair Nerve compression TOS neuromas radial nerve palsy median nerve palsy ulnar nerve palsy combined nerve palsies brachial plexus tetraplegia open hand injuries combined injuries RA RA elbow Skin grafts Skin flaps Acute flexor tendon Late flexor tendon Acute extensor tendon Late extensor tendon Tenosynovitis Burned hand Frostbite Thumb recon Ganglions Skin tumors Tumor principles Tumors Vascular disorders

Chapter 1 – General Principles (David P. Green) 1) 2) Careful attention to detail and precise, gentle technique are essential for success. Know when to quit. Sometimes you can not restore the hand to normal.

TAM=total active motion TPM = total passive motion Example: MCP 0-90

PIP 10-95 -----------( DIP 0-60

245-10=235 TPM

3) Tourniquets A A) 2 hours max time B B) readjustment interval 15-20 min (pH from 6.90 to 7.40) C C) 250 mm Hg – adults (may need 300-350 if obese, muscular, hypertensive), 200 mm Hg – children D D) 12-18 inch cuff as high in the axilla as possible; use sterile tourniquet if surgery at distal humerus E E) don‘t Esmarch over cyst, with tumor, infection (alt. method: elevate arm and cx brachial a. x 1 min.) F F) when let down tourniquet? After cx dsg, except: dissection near major aa., Dupuy‘s and other procedures where vascularity at risk, CTR (Green)/ G G) forearm tourniquet: some report less pain. Use if A-V shunt in arm, Norplant in arm H H) Salem finger tourniquet: rolled glove finger (JHS ‗86-consistent pressure < 500mm Hg, Penrose inconsistent, > 500mm Hg) 1) Magnification 2.5-4.5 loupes are key in hand surgery 2) Safety hand position – puts ligaments at longest position to minimize contractures and stiffness A) wrist 30-45 degrees extension B) MCP‘s 70-90 degrees flexion C) IP‘s fully extended 1) A) B) Post-op elevation: ―keep the hand higher than the elbow‖-Green Provost pillow method

Chapter 2 – Anesthesia (Somayaji Ramamurthy, Rosemary Hickey) 1) Numerous advantages to regional anesthesia: Safer re: aspiration, decreased N/V/drowsiness, easier post-op management 2) Local anesthetic mechanism: prevents action potential by interfering with sodium channels 3) Local anesthetics-less effective in inflamed area because of increase acidity 4) Reactions to intravascular anesthetic injection: metallic taste, numbness around mouth, ringing in ears, twitching of face, convulsions.


Epinephrine: prolongs anesthesia, delays intravascular uptake (decreases toxicity).

a. Do NOT use in digital blocks or in patients with CAD 6) REGIONAL ANESTHESIA: brachial plexus blocks, elbow and wrist blocks, digital blocks, intravenous blocks. 7) Intraneural injections may injure the nerve 8) Brachial plexus blocks (supraclavicular, interscalene, subclavian, axillary, parascalene, infraclavicular) 9) Axillary block most common hand surgery block (easy, low complication rate, addresses tourniquet pain) 10) ELBOW BLOCK rarely performed-does not address tourniquet pain. May use to supplement an incomplete brachial plexus block a. Ulnar n.: 5cc at cubital tunnel a. Median n.: 5-10 cc just medial to brachial a. at line between epicondyles. Identify by paresthesias. a. Radial n.: 5-10cc 3-4 cm proximal to lateral epicondyle a. Medial and lateral antebrachial cutaneous nn: subQ ring around elbow 11) WRIST BLOCK: very useful and commonly used a. Median n.: 5cc between FCR and palmaris longus at proximal wrist crease after popping through TCL a. Ulnar n.: 5cc just radial to FCU (avoid ulnar a.-just radial to n.). 5cc subQ from 1st injxn to midpoint of dorsum wrist to get dorsal ulnar cutaneous n. a. Radial n.-superficial branch: 5cc from radial a. to midpoint dorsal wrist (effectively for all cutaneous nn.: subQ ring of entire wrist) 12) DIGITAL BLOCK a. Do NOT perform ring block (gangrene can result) a. VOLAR APPROACH: skin wheal over flexor tendon at distal palmar crease & 2-3cc on each side of flexor tendons a. DORSAL APPROACH: skin wheal dorsally, 1-2 cc at each webspace almost to volar skin a. FLEXOR TENDON SHEATH APPROACH: 2cc in sheath at distal palmar crease 13) BIER BLOCK (=intravenous regional anesthesia) a. Thorough exsanguinations most important part a. 1 hour max 14) BLOCK FOR RSD OF THE UPPER EXTREMITY=STELLATE GANGLION BLOCK a. Causes sympathetic block a. May need repeated injections, indwelling catheter, or even ganglionectomy Chapter 3 – Amputations (Dean S. Louis, Peter J. L. Jebson, Thomas J. Graham) 1) 2) 3) a. a. a. a. Causes: trauma, elective involving congenital deformity, malignant tumors Functional rehabilitation is primary consideration following amputation Goals of amputation surgery: Preservation of functional length Durable coverage Preservation of useful sensibility Prevention of symptomatic neuromas

a. Prevention of adjacent joint contractures a. Short morbidity a. Early prosthetic fitting when applicable a. Early return to work and play 4) Digital Tip Amputations (including thumb) a. Most common type a. Provokes greatest controversy a. APM-conservative: heal by secondary intention (BID wet to dry dressing changes by the patient). If bone exposed, rongeur back to no exposed bone. No splint. Treated in ER: digital block, clean/debride wound. F/U in 2-3 days. Oral antibiotics not routinely given-only if diabetic or immunocompromised or wound grossy contaminated. a. Primary closure and STSG – worse results a. Cold intolerance – 30-50% and sensibility aberration 30% no matter how treated. These features are a consequence of the injury and not the treatment. a. Coban wrap and ROM after 48 hours- Occupational therapy home program a. Tip desensitization after fully healed a. Avoid hooked nail: nail bed should be at same level of bone. Do not pull nail bed down over bone a. Variety of flaps/closure methods (not advocated by the author): Atasoy-Kleinert Volar VY Flap, Kutler Lateral V-Y Flap, Volar Flap Advancement (Moberg), Cross-Finger Pedicle Flap, Thenar H-Flap (Smith & Albin) i. Atasoy-Kleinert Volar V-Y Flap: full thickness skin flap cut from volar pad-triangle with base at distal cut edge and apex at DIP crease. Separate between flexor sheath and SQ tissue & advance. Close in Y configuration.

i. Kutler Lateral V-Y Flap: 2 full thickness skin flaps laterally (triangles similar to AtasoyKleinert). Connect 2 triangle bases. i. Volar Flap Advancement (Moberg): 2 midlateral incisions made and volar flap on entire digit mobilized distally. Limited to 1 cm advancement. More appropriate for thumb. Disadvantages: possible necrosis of entire volar flap, possible fixed flexion deformity of DIP. i. Cross-Finger Pedicle Flap: example-laterally based flap from dorsal middle phalanx to tip of adjacent finger. Cover defect with FTSG (i.e.volar forearm). Detach pedicle after 2 weeks. i. Thenar H-Flap (Smith & Albin): H shaped flap from skin over thenar eminence-detach after 2 weeks. Most applicable for digits 2&3. (Contraindications for cross-finger or thenar H: any condition that may lead to stiffness such as RA, Dupy‘s, connective tissue d/o, >30 y.o. 5) Amputations from DIP to MCP a. Through DIP: shorten bone (take off condylar prominences), transect digital nn., do not suture tendons together, close (fishmouth technique). Possible complication: lumbrical plus finger (FDP retracts and as flexion is attempted, tension on unopposed lumbrical-lateral band impairs active PIP flexion). Treated later with lumbrical sectioning. a. Through Middle Phalanx: shorten bone and close (like DIP) a. Through PIP: like DIP a. Through Proximal Phalanx: like middle phalanx

a. Through MCP: consider prosthetic replacement or more proximal ray amp and defect closure since this causes functional problem of dropping small objects through the defect. 6) Ray Amputations (from trauma, infection, tumor, failed replantation, congenital defect) a. Index Ray Amputation a. Long Finger Ray Amputation: either move 2nd MC over and fix with K wires (Carroll) or plate OR just suture 2nd and 4th deep intervolar plate ligaments to close the space a. Ring Finger Ray Amputation: Excise entire 4th MC and suture deep intervolar plate ligaments of 5th and 3rd MC—5th MC will slide over. Transfer of 5th MC to 4th MC base and fixation with K-wires or plate is an option, but has the morbidity of the healing osteotomy. a. Fifth Ray Amputation: Must preserve MC base because of FCU and ECU insertions. 7) Multiple Digit Amputations a. Save all viable tissue. Reconstruct at later date. 8) Amputation Through Carpus a. Save as much as possible. Small amount of wrist flexion can hold objects against body. 9) Wrist Disarticulation a. Preserve DRUJ and TFCC- allows full supination/pronation. Also preserve radial styloid flare-improves prosthetic suspension. Fishmouth closure. 10) Forearm Amputations (below elbow) a. Preserve maximum length-preserves maximum sup/pronation a. Fishmouth closure. a. Prosthetic fitting after stump shrinkage done-usually 6 weeks. a. Even 2 inches ulna adequate for prosthesis. Detach biceps and reattach proximally to ulna. a. Krukenberg: convert forearm stump into radial and ulnar pincer rays motored by pronator teres. Indication: blind bilateral amputee. Relative indication: sighted bilateral amputee. Done on dominant side. Need at least 10 cm length from olecrannon tip and elbow contracture < 70 degrees. May also use standard prosthesis. 11) Elbow Disarticulation a. Better than above elbow since allows transmission of humeral rotation to prosthesis from snug fit over condyles. 12) Above Elbow Amputations a. Preserve maximum length a. Prosthesis need suspension harness 13) Amputation of Arm at Level of Pectoralis Major a. Will function like shoulder disarticulation a. Preserving proximal humerus gives contour and better purchase of prosthesis 14) Shoulder Disarticulation 15) Forequarter Amputation a. Principally used for malignancy, only for life-saving measure. a. Clavicle, scapula, and U.E. removed a. Anterior approach (Berger) or Posterior approach (Littlewood) – both from lateral position 16) Radical Forequarter

Amputation a. Also includes chest wall 17) Tikhor-Linberg Procedure – resection of the shoulder girdle (clavicle, scapula, proximal humerus) with preservation of the arm 18) EARLY post surgical prosthetic fitting important! 19) Post amputation Pain Problems a. Desensitization Modalities – early return to functional activities, intensive programs of resensitization to textures and objects a. Phantom Limb Pain – poorly understood and difficult to treat i. Studies on L.E. amps show decrease in phantom limb pain with peri-op epidural anesthesia or post-op intraneural anesthesia applied to the transected nn. a. Painful Neuromas i. Sharply transect nerves and bury nerve endings deeply and proximally where there will be no friction from prostheses a. Psychological Aspect of Hand Amputations i. Injuries can lead to PTSD and flashbacks i. Psychiatric evaluation within 3 days of injury helpful Chapter 4 – SMALL JOINT ARTHRODESIS (Andrew J. Weiland) INDICATIONS: pain, instability, deformity, loss of neuromuscular control. May be from posttraumatic arthrosis or deformity, fixed contracture after burns, RA, chronic infection, fixed deformity from Dupuytrens, nerve palsies leading to instability, failed motion saving procedures. -Joints usually fused: PIP & DIP. MCP motion usually preserved with arthroplasty. -DIP: specific indications: FDP rupture where reconstruction not indicated, mallet finger -Thumb MCP: causes: RA, neglected or failed ulnar or radial collateral ligament injuries, hyperextension deformity associated with basal joint OA or ulnar nerve palsy. -Basal joint may be fused, but less commonly—considered when power is more important (heavy laborers) or when soft tissue stabilization not possible. If fuse, need motion proximal and distal. ->90% fusion success -Caution with insensate hand, as they are difficult to fuse and behave as Charcot‘s joint POSITION OF ARTHRODESIS: -control all planes: A/P, R/U, rotation -MCP cascade from radial to ulnar with 25 degrees at index, add 5 degrees to end with 40 degrees at 5th digit. No R/U, rotation. -PIP cascade from 40 degrees at index, add 5 to end with 55 at 5th. 5-10 degrees supination for 2nd and 3rd digits to help pinch. -DIP: 0 degrees. -THUMB: IP in slight flexion (0-15 degrees). MCP flexed 5-15 degrees with 10 degrees pronation to aid pinch. CMC at 40 degrees palmar abduction and 20 degrees radial abduction with pronation to aid pinch. SURFACE PREPARATION AND SHAPING: -either flat angled resections (must be precise) or ―cup and cone‖

METHODS OF FIXATION: -K-WIRES: 0.045 inch for MCP and basal joints, 0.035 inch for PIP & DIP. 1 down center and 1 obliquely, or 2 crossed. -INTEROSSEOUS WIRING: 90-90 technique. Medial-lateral and dorsal-palmar holes made with 0.035 inch K-wire 3 mm from ends, 26-gauge stainless steel wire introduced through 20gauge needle. Stronger than K-wires. Not recommended in RA or osteopenia (cut out) -TENSION BAND: transverse hole made in distal bone 8-10 mm from end with 0.035 inch Kwire, 26-gauge passed through. 2 parallel 0.035 inch K-wire passed and figure 8 wire around. -INTERFRAG AO COMPRESSION SCREW: 2.7mm screw lagged with glide/pilot technique. Best for PIP & DIP -HERBERT SCREW: Best for PIP & DIP -PLATE FIXATION: Dorsal 3 to 5 hole mini plates (2.0 or 2.7 mm). Best if segmental bone loss. -EX-FIX: useful if open injury with bone/soft tissue loss, septic arthritis, osteomyelitis, failed prior arthrodeses. -BIOABSORBABLE RODS AND PINS: early studies promising. Made of polylactic acid that is degraded by hydrolysis to lactic acid monomer, then degraded to CO2 and water. BONE GRAFTING: -not usually needed, unless significant bone loss, failed arthrodesis or arthroplasty, infection, arthritis mutilans RA. Graft from distal radius, or olecranon. ARTHRODESIS WITH OPEN PHYSES: -rare, but may need in congenital problems or CP. Articular cartilage removed with knife perpendicular to shaft, but do not excise ossification center or physeal plate. Fix with 2 crossed 0.035 K-wires. COMPLICATIONS: -vascular insufficiency, nonunion, malunion, cold intolerance, infection. APM: -POST-OP: -tendons repaired with 4-0 nonabsorbable sutures and skin with 5-0 nylon suture. Hand immobilized for 4-5 days, then splint 1 joint and allow motion of other joints x 6 weeks. DIP and THUMB IP: -expose with H-shaped incision, inverted U or Y incision. Extensor tendon sectioned at base of distal phalanx with care to avoid damage to germinal matrix of nail. Joint capsule incised transversely, collateral ligaments excised. Flex joint to expose ends, prepare. Herbert screw: long drill through distal phalanx from proximal to distal out tip; drill long retrograde into middle phalanx; drill larger in distal phalanx; insert Herbert screw until flush with tip of bone. If small hand, crossed K-wires, or single horizontal interosseous wire (26-gauge) and oblique K-wire (0.035 inch). For thumb, consider 90-90 interosseous wiring. PIP:

-dorsal longitudinal incision, incise extensor tendon and joint capsule longitudinally as unit in midline; elevate. Release central tendon insertion and proximal origins of collateral ligaments. 90-90 technique if normal bone, crossed K-wires if not. MCP FINGERS: -longitudinal skin incision; longitudinal incision through radial side of extensor tendon and joint capsule. Excise collaterals. Bent mini plates. MCP THUMB: -dorsal longitudinal incision between EPL and EPB, incise joint capsule, collaterals excised. 9090 for normal bone, crossed K-wires if not. CMC: -basal joint: expose volar (as in LRTI), fuse with mini-plates. -digits 2-5: transverse incisions, fuse with mini-plates or screws alone. CHAPTER 5 – INTERCARPAL ARTHRODESIS (Watson, Weinzweig) -Also called Limited Wrist Arthrodesis -Indications: degenerative wrist disorders, rotatory subluxation of scaphoid, midcarpal instability, scaphoid nonunion, Kienbock‘s, carpal osteonecrosis, congenital synchondrosis -Intercarpal arthrodesis can maximize motion, function, strength and decrease/eliminate pain and instability WRIST MOTION -After limited wrist arthrodesis, there is compensory increase in motion of unfused joint; takes 912 months to achieve -Flexion: 2/3 at radiocarpal joint and 1/3 at midcarpal; extension slightly more at radiocarpal (Gellman, JHS, 1988) -Greatest loss of motion from radiocarpal fusion, then midcarpal, and least within carpal row -ADL‘s need 5 degrees flexion, 30 extension, 10 RD, 15 UD (Palmer, JHS, 1978) – all limited arthrodeses surpass this, except radio-ulnar deviation in RC fusion PRINCIPLES OF INTERCARPAL ARTHRODESIS -Unaffected joints left unfused -Preserve normal external dimensions of the fused carpal bones (except in SLAC reconstruction) -Fix only bones involved in arthrodesis TRISCAPHE ARTHRODESIS (=STT fusion) -Indications: dynamic and static rotatory subluxation of scaphoid (RSS), persistent symptomatic predynamic RSS with instability, degenerative disease of trischaphe joint, scaphoid nonunion, Kienbock‘s, scapholunate dissociation, traumatic dislocations, midcarpal instability, congenital synchondrosis of triscaphe joint -Contraindicated if significant degenerative disease in radioscaphoid joint ROTATORY SUBLUXATION OF THE SCAPHOID (RSS)

-Usually from loss of connection between scaphoid and lunate; scaphoid rotates with distal pole volar and dorsal displacement of proximal pole. Increased scapholunate (SL) angle (>60 degrees) on lateral x-ray -This subjects RS joint to abnormal stress and eventual degenerative changes and SLAC wrist -Less commonly caused by triscaphe degenerative disease PATHOMECHANICS -Scaphoid fossa is ovoid/elliptical; lunate fossa is spherical -In RSS, scaphoid malrotates

(Watson‘s 2 spoon analogy) and incongruous loading occurs, leading to degeneration (SLAC) -SLAC = scapholunate advanced collapse. (1) Stage IA = degeneration at radial styloid. (2) Stage IB = degeneration at RS joint. (3) Stage II = degeneration at CL joint. (4) Stage III = proximal migration of capitate = carpal collapse. (some authors: I, II, III, IV) -RL joint preserved because of spherical lunate fossa maintains congruous loading; even in DISI (dorsal intercalated segment instability) or less commonly VISI CLASSIFICATION – 5 types of RSS -Type I = Predynamic RSS: signs and symptoms of scaphoid instability exist (see below), but normal x-rays -Type II = Dynamic RSS: normal PA and lateral x-rays, but stress views reveal abnormality: (1) > 3mm SL gap with clenched fist view, (2) maximum flexion / extension and RD / UD views reveal asymmetric rotation -Type III = Static RSS: PA and lateral x-rays reveal (1) SL gap, (2) increased SL angle (>60 degrees), (3) +/- DISI, (4) scaphoid ring sign (=overlapped proximal and distal poles on PA view), (5) foreshortened scaphoid -Type IV = Degenerative RSS: SLAC or STT degenerative changes -Type V = Secondary RSS: Involvement of scaphoid from secondary lesions (i.e. Kienbock‘s) CLINICAL PRESENTATION OF RSS -At least 3 on the following 5: (1) Activity pain: usually chief complaint. Usually radial, but can also be ulnar in severe RSS. May radiate. (2) Postactivity Ache: can last for hours to days, (3) Activity Modification, (4) CTS Symptoms: intercarpal synovitis causes median nerve compression, (5) Wrist Ganglions PHYSICAL EXAMINATION (5 Maneuvers) -Decreased ROM. Especially any loss of passive flexion signifies carpal pathology -DORSAL WRIST SYNDROME (DWS) / SCAPHOLUNATE JOINT – Direct palpation of SL joint, identified in line with 3rd metacarpal, just distal to radius, and between ECRB and 4th compartment. Normal joint is non-tender; if tender, DDX: SLD, Kienbock‘s, DWS. -FINGER EXTENSION TEST (FET) – Hold wrist passively in flexion and resist active finger extension. If painful, DDX: RSS, Kienbock‘s, RC or midcarpal instability, DWS. -ARTICULAR-NONARTICULAR (ANA) JUNCTION OF SCAPHOID – Palpate the ANA junction: radially deviate the wrist; firmly palpate the scaphoid just distal to the radial styloid and

ulnarly deviate the wrist. Normal wrist demonstrates mild to moderate tenderness; pathologic one with severe pain (DDX: synovitis, scaphoid instability, SLAC). Perform bilaterally. -STT – Palpate the STT by following the 2nd metacarpal proximally until falls into recess = STT. If tender, then STT degeneration or synovitis SCAPHOID SHIFT MANEUVER -Qualitative assessment of scaphoid stability and synovitis -Must compare to contralateral side -Patient‘s elbow on the table with hand pointing upwards, slightly pronated. Examiner‘s right thumb placed on patient‘s right distal pole of scaphoid. Examiner‘s other hand directs patient‘s wrist: starting in ulnar deviation and slight extension, wrist is moved radially and slightly flexed while maintaining constant pressure on scaphoid with thumb -Therefore, the patient‘s scaphoid starts extended but palmar flexes as wrist is radially deviated. In a wrist with rigid periscaphoid ligamentous support, only minimal shift is tolerated before the scaphoid rotates and pushes the examiner‘s thumb out of the way. -If there is ligamentous laxity (either acquired or congenital) the scaphoid will be subluxed dorsally with this maneuver, and upon releasing the thumb pressure, the scaphoid will ―shift‖ (reduce) back into place. If there is crepitus, this may signify chondromalacia -If this maneuver reproduces the pain, and there is unilateral laxity demonstrated, then this is virtually diagnostic of RSS or scaphoid non-union. TREATMENT (APM) -If RSS secondary to acute injury, and < 3 weeks since injury, then ORIF with K-wires., Establish normal S-L-C relationship and pin all 3. May need to pin S & L to R as well. Direct

ligament repair ―also recommended when feasible‖. LAC ―Groucho Marx‖ x 4 weeks, then SAC x 4-6 weeks. -If > 3 weeks, APM = STT fusion. -Watson: STT results: 80% F/E and no secondary degenerative changes with time. (Other authors: ligament reconstruction +/- Blatt capsulodesis) SCAPHOID NON-UNION -3 indications for triscaphe arthrodesis: (1) If very small (mm‘s) proximal fragment, bone graft fracture and STT fusion, (2) If very distal fracture, bone graft and STT fusion, (3) If simultaneous scaphoid fracture and SLD, then BG and STT fusion KIENBOCK‘S -TREATMENT (APM): STT fusion (unloads lunate). Other choices: (1) radial shortening vs. ulnar lengthen +/- lunate revascularization (most popular), (2) PRC (salvage) SLD -TREATMENT (APM): If degenerative changes in RS or CL joints, then SLAC reconstruction (see below). If not, then STT fusion.

STT DISLOCATION -Rare -Mechanism: force to hand in R-U vector -Trapezium and trapezoid dislocate from scaphoid, usually dorsally. Treatment: reduce and STT fusion MIDCARPAL INSTABILITY -Distal scaphoid support is sufficient and distal carpal row collapses on proximal row; VISI deformity -TREATMENT (APM): If RC joint intact, then STT fusion. STT DEGENERATIVE DISEASE -TREATMENT (APM): STT fusion. CONGENITAL CARPAL SYNCHONDROSIS (=incomplete separation of carpal bones) -May lead to degenerative changes and pain -Often asymptomatic and found incidentally -Fuse if symptoms severe -Most common: LTq, then CH, STT TRISCAPHE (STT) ARTHRODESIS TECHNIQUE -4 cm transverse dorsal wrist incision just distal to radial styloid -Spread and protect veins and radial nerve branches -Expose the radial styoid through capsular incision at the styloid-scaphoid junction and remove distal 5 mm of the styloid with a rongeur -Transverse incision is made in the dorsal capsule and the RS joint is inspected. If there is significant degenerative disease (despite normal x-ray), then do SLAC procedure (see below) -Otherwise do STT fusion: -Open distal extensor retinaculum over the EPL -Approach STT through transverse capsular incision between ECRL and B. -Remove entire articular surfaces and subchondral bone of S, T, & T with rongeur. Dorsal cortex also removed to broaden fusion surface -Harvest cancellous bone graft from distal radius (see below) -Place 2 x 0.045-inch K-wires (pre-set) into the trapezoid dorsally (from distal to proximal) aiming at scaphoid -Place wrist in full RD and 45 degrees DF while distal pole of scaphoid reduced by surgeon‘s thumb -A 5-mm spacer (usually handle of small hood) is placed in scapho-trapezoid space to maintain external STT dimension and K-wires driven. Only drive pins into scaphoid. Check x-ray: SL < should be 55 degrees. -Pack cancellous bone into STT, cut pins under skin. No suture in capsule/retinaculum -Long-arm splint, wrist slight extension and radial deviation, neutral forearm, elbow 90 degrees. POST-OPERATIVE -3 weeks in LATSC (―Groucho Marx‖: thumb to tip, index and middle MCP‘s at 90 degrees and IP‘s free) -3 weeks in SATSC

-X-rays at 6 weeks; if union, then d/c pins and start hand therapy RESULTS (Watson) -80% ROM at 1 year -Grip strength 90% -Rare progressive degenerative changes DORSAL RADIUS BONE GRAFT – TECHNIQUE -3 cm transverse (or longitudinal) incision made 3 cm proximal to radial styloid, from Lister‘s tubercle to just volar to 1st dorsal compartment. -Spread to expose flat periosteal surface between 1st and 2nd extensor compartments, which is identified by a constant periosteal artery running longitudinally . Incise periosteum and this dispensable artery and elevate to remove a teardrop-shaped cortical window 2cm long by 1.5 cm wide with a narrow, straight osteotome. -Harvest cancellous bone graft with 8 mm curette and replace window. -Replace periosteum and tendons,

close skin. SLAC WRIST -Most common degenerative wrist pattern -Most common cause for SLAC is RSS, followed by scaphoid non-union. Others: Preiser‘s, midcarpal instability, Kienbock‘s -See ―pathomechanics‖ for SLAC stages SLAC WRIST RECONSTRUCTION TECHNIQUE (=4 corner fusion=4 bone fusion) Need: rongeurs, curettes, osteotomes, 2mm burr, 0.045 K wires & driver, fluoro, micro-sag saw -Dorsal oblique longitudinal incision in line with 3rd ray -Through skin, SQ, protect nerves and veins -Incise retinaculum over 3rd compartment, open 3rd, move EPL and ECRB & L radially, subperiosteally lift 4th compartment ulnarly -Incise capsule from capitate to 1 cm into radius – open like book – preserve palmar and radial ligaments -Excise scaphoid (quarter with micro-sag saw, osteotome, rongeur, freer, 15 blade) -Denude C H L Tq surfaces – use above instruments -Scaphoid bone graft – may need small window in metaphyseal distal radius – osteotome / curette -Preset 0.045 K wire C, H, Tq to L, Tq to C -Pack bone graft -Reduce capitate volarly (reduce DISI) and ulnarly & drive K-wires thru -Check with fluoro -Pack more bone graft -Close retinaculum & capsule with 3-0 absorbable suture, etc LATSC x 3 weeks, then 3 weeks SATSC, then d/c K-wires, then remove. Splint x 3 wks

-Do not perform if lunate or RL pathology -Coaxial alignment of L & C essential -Sufficient preparation of bones essential for fusion LTq ARTHRODESIS -Ulnar wrist pain -Indication for arthrodesis: instability, degenerative OA, symptomatic synchondrosis -Exam: Tender LTq and positive LTq ballotment test -LTq instability is associated with ulnar positive variance; secondary to ulnar impaction with resultant LTq interosseous ligament disruption and LTq dissociation -If partial LTq ligament tear and not grossly unstable, then may treat with ulnar shortening. However, complete tear and gross instability necessitates LTq arthrodesis LTq ARTHRODESIS TECHNIQUE -Expose LTq joint though transverse dorsal ulnar incision and similar capsular incision -Remove cartilage / subchondral bone with rongeur -Preset 2 x 0.045-inch K-wires in Tq and while maintaining external dimension, drive pins across to lunate -Pack with cancellous bone graft (from radius) -SAC & pins x 6 weeks C-L ARTHRODESIS -Rare (for articular CL fractures, isolated CL OA, bony lesions) Tq-H ARTHRODESIS -rare SL ARTHRODESIS -avoid doing; high non-union rates RL ARTHRODESIS -Only indications in non-RA patient: ulnar translation and destruction RL joint Chapter 6 – Wrist (radiocarpal) Arthrodesis (Hill Hastings II) F/E 50% from radiocarpal, 50% from intercarpal 1) Indications: a. Post-traumatic OA a. Failed limited arthrodesis a. Failed TJA a. Paralysis with potential tendon transfers a. Segmental loss from tumor resection or infection a. Spastic hemiplegia with wrist flexion deformity a. RA 2) Contraindications:

a. Open physis a. Nondominant hand in elderly with light activity (TJA instead) a. Neuro path with major sensory loss 3) APM- Surgical technique: AO plate a. Dorsal approach: 2nd & 3rd interspace thru Lister‘s, open 3rd compartment & transpose EPL radially, capsulotomy longitudinal, subperiosteally elevate 2nd & 4th compartments from carpus and radius (do not open) a. With osteotome, rongeur, burr, remove Lister‘s and dorsal cortices of 3rd base, dorsal 25% carpal bones, and articular surfaces of RS, RL, LC, SC, 3rd CMC joints. Leave ulnar side to preserve supple motion, unless arthritic. a. Bone graft: use local cancellous from dorsal DR and carpus. May need additional from cortical window of DR (radial to plate and 2cm prox to joint) and olecranon and ICBG a. Plate: AO titanium LC-DCP – short if PRC, long, straight if large

defect. Preset 10 degree extension. May also use standard AO plates (recon, LC-DCP). a. Preserve distal ulna. Resect Tq if impingment. a. Post-op: splint 1-2 weeks, then removable splint 4 weeks 4) Other techniques: 1) Carroll, Dick: dorsal with ICBG, 2) Capitate-radius, 3) Radial Haddad-Riordan 5) Complications: a. Lower complication rate with AO plate (14%) vs. non-AO (28%) a. Lower non-union rate with AO plate (0-2%) vs. non-AO (18%) a. Hardware tender, adhesions, CTS, ICBG, DRUJ, RSD, wound healing prob, unexplained pain Chapter 7 – Arthroplasty in the Hand and Wrist (Richard Berger, Robert Beckenbaugh, Ronald Linscheid) -Indications: pain, stiffness, deformity. Most commonly from RA, but also OA -always consider arthrodesis as major alternative 1) DIP: arthrodesis usually preferred. May use Swanson implant-get 25-30 degrees motion, usually with 10-30 degrees extension lag. TECHNIQUE: distally based Y incision from middle of middle phalanx to nail. Divide extensor tendon 5mm from joint and retract distally. Remove ends, ream, implant. Repair extensor tendon, maintain DIP extension 6 weeks. 2) PIP: usually arthroplasty, not arthrodesis (cannot make fist). Implant either silicone or surface replacement arthroplasty (SRA)-chromium-cobalt proximal component and UHMW polyethylene distal component. a. Resectional arthroplasty (Carroll-Taber). Indicated if sepsis. TECHNIQUE: mid lateral incision. Resect proximal phalanx at neck. Transverse wire through middle phalanx and traction outrigger x 6 weeks. a. Swanson silicone elastomer arthroplasty: indication usually for OA, not RA. Not recommended to arthroplasty contiguous (MCP & PIP) joints. If multiple fingers, fuse index PIP

in 20-40 degrees and arthroplasty others (needed for grasp). TECHNIQUE: dorsal C-shaped incision. ―central tendon-sparing‖ technique used: exposure made between lateral band and central tendon (slip). Collateral ligaments and palmar plate released proximally to dislocate joint laterally. If stiff joint preop, check flexor tendon excursion. If cannot access tendons through dorsal wound, make trigger finger incision and check, may need to release A1 pulley. Resect ends, ream canals, implant (no grommets at PIP). 4-0 sutures though 0.5 mm drill holes in proximal phalanx for collateral ligament repair. Immediate hand therapy ROM, buddy tape. May use lateral (volar to lateral tendon) or volar (distally based volar capsule/plate flap) approaches, but dorsal approach with superior results. a. Boutonniere correction: i. Matev TECHNIQUE: radial lateral tendon incised over middle of middle phalanx, freed and moved through the extensor tendon over the proximal phalanx to the base of middle phalanx. Ulnar lateral tendon incised distally over middle phalanx and sutured to remnant of distal portion of radial lateral tendon. i. Other TECHNIQUE: central slip advanced and sutured through drill holes at base of middle phalanx. Lateral tendons released from contracted transverse retinaculum and sutured to each other over dorsum PIP. If DIP will not flex, make oblique or ―V‖ tenotomy through extensor mechanism over middle of middle phalanx and manipulate DIP into flexion. a. Surface replacement arthroplasty (SRA-both components cemented): (some criticize silicone for limited ROM and instability). Implantation similar to Swanson. May elevate extensor mechanism as a distally based flap. a. Perichondral grafting: transplanted perichondrium from costal cartilage to cartilage defects (MCP, PIP). Louisville group with disappointing results. 3) MCP: OA rarely affects MCP, usually RA. Arthrodesis rarely performed since functionally limiting. May consider index MCP fusion (stablizes pinch and protects against other digits(ulnar deviation). If significant disease at PIP and MCP, fuse PIP. Balance/reconstruct wrist first. -need to balance soft tissues. Ulnar collateral ligament and capsule contracted (try to preserve, but may need release). Radial collateral ligament attenuated and will need incision and imbrication. Need to centralize extensor and flexor tendons. After arthroplasty, check intrinsic tightness test and do distal intrinsic release if needed (see Ch 19). If passive extension of MCP is restricted or if persistent volar subluxation, then release entire intrinsic mechanism. Check flexor tendons for excursion-may need to go volarly. a. Soft tissue arthroplasty: Vainio technique (if attenuated extensor mechanism): resectional arthroplasty, extensor tendon divided and sutured to volar base of proximal phalanx as interposition material. Tupper technique: resectional arthroplasty, and distally based volar plate flap used as interposition material, sutured to dorsal metacarpal head through drill holes. a. Bony arthroplasty: Fowler-metacarpal head chevron shaped and proximal phalanx base ―V‖ shaped. a. Joint Replacement: preferred technique. Swanson remains standard implant. TECHNIQUE: transverse skin incision made over necks of metacarpals. Incise radial border of extensor hood and imbricate. Only incise ulnar border if must. Metacarpal head and base PP transected. Soft tissue release to correct angular deviation and palmar subluxation. UCL released from phalangeal insertion, possibly from palmar plate. Ulnar intrinsic tendon sectioned if tight. Flexor sheath incised longitudinally and tenosynovectomy done if needed. If unable, turn over and zig incision over A1-A2. Canals reamed and trial implants. If good bone stock, consider

titanium grommets to protect bone-implant interface. May need to reconstruct or imbricate the RCL. Reattach with 3-0 Dacron suture through 0.5mm drill holes as needed. Centralize extensor tendon. Splint MCPs in extension and slight radial deviation, and IPs in slight flexion. Hand therapy, ROM post-op. (other implants: Sutter silicone, NeuFlex-30 degree at rest-increased flexion, Surface replacement arthroplasty (SRA-both components cemented). CROSSED INTRINSIC TRANSFER: If need additional dynamic stabilization against ullnar drift- move ulnar inerosseous to distal portion of RCL. 4) MCP of thumb: If IP and CMC not diseased, arthrodesis is preferred. However if IP and MCP diseased, common to fuse IP and arthroplasty MCP. Silicone or cemented Steffee used. a. Swanson silicone: oblique longitudinal incision dorsally over MCP. Extensor hood incised form EPL. EPB detached from PP. Metacarpal head and PP base resected. May need to release volar plate and collaterals if flexion contracture. Ream shafts and implant. EPB advanced to PP. EPL sutured to PP to allow easy passive flexion IP. If IP hyperextended and not diseased, may K-wire IP flexed and hemitenodese ½ of FPL to PP. Splint 4 weeks. a. Cemented Steffee: does not have problems associated with fingers-not avail in US. 5) Basal Joint Arthritis in the Thumb (CMC arthroplasty-JAAOS-Barron, Glickel, Eaton) a. More common in women a. volar beak ligament from base of 1st MC to trapezium(primary restraint to dorsoradial subluxation a. Hx: pain, decreased pinch strength a. PE: prominence, possible adduction contracture, focal tenderness, check ROM-especially between 1st and 2nd MC, check laxity. Grind test, distraction test, pinch strength. a. x-ray: special views: 1) basal joint stress view=PA 30 degree oblique while pressing opposing thumb tips together. 2) key pinch lateral. a. Stages: I) no degeneration. Joint space widening or mild subluxation. II) narrowing joint space and osteophytes < 2mm. normal ST joint. III) like II, but >2mm. IV) degenerative changes of ST and TM joints. a. TREATMENT: Non-operative: 1) activity modification 2) NSAIDs 3) Splinting 4) +/corticosteroid injection. Operative if fails. Most perform LRTI (ligament reconstruction tendon interposition Ligament Reconstruction Tendon Interposition (LRTI) - TECHNIQUE 1. EXPOSURE (Wagner): Incision-border of glaborous and dorsal skin of thenar eminence, then over FCR. Start 2 cm distal to TM joint, end 4 cm proximal to proximal volar wrist crease. Watch for superficial radial nerve (in dorsal flap) and radial artery (sometimes there is a crossing branch that you must preserve, otherwise may not see either nerve or artery). Lift thenar muscles off carpal capsule with 15 blade. Open FCR sheath. 2. longitudinal capsulotomy over trapezium, TM joint, ST joint. Expose base of 1st MC. Extend capsulotomy to FCR, distally FCR goes dorsal to trapezium( rongeur the trapezium at this point. 3. excise trapezium- quarter with micro-sag saw, osteotome (turn and crack), rongeur—shell out. Also use 15 blade and Freer elevator. 4. osteotomize end of 1st MC with micro-sag saw perpendicular to long axis

5. make oblique hole in base of 1st MC with progressively larger drill bits, end with 5mm. Begin at dorsal cortex (in line with nail) 1 cm distal to base and aim at spot of volar oblique ligament 6. divide FCR at musculotendinous junction (make transverse incision 10 cm proximal to proximal volar wrist crease). Whip/purse suture the FCR end (3-0 ethibond) and pass thru tunnel of 1st MC with suture passer. 7. Optional: Hold 1 MC in ideal position (abducted fist) with 2 K wires (1st MC to 2nd and 1st MC to trapezoid/capitate). If not done, then hold thumb in ideal position and proceed to 8. 8. Taut FCR secured to 1st MC periosteum, then to itself deep in the a-plasty space (all with 3-0 ethibond) 9. make anchovie: roll tendon over non-toothed forceps and place 4 sutures radially around roll, simple sutures with 3-0 ethibond 10. 1 deep suture placed on trapezoid periosteum, then thread these thru anchovie 11. close capsulotomy 12. divide EPB distally and suture to FCR and 1st MC base periosteum 13. 14. close skin SATSC x 4-5 weeks, then d/c pins and removable TSS and gentle ROM x 4weeks

TECHNIQUE – ALTERNATIVE -CMC exposure through longitudinal incision over snuffbox, protecting radial nerve branches and radial artery. -Expose trapezium through longitudinal preserving capsular incision. Excise trapezium -Release whole FCR proximally at MT junction through transverse incision 10-15 cm proximal to wrist -Pull FCR out thumb wound -Make oblique tunnel through base of thumb metacarpal to point of volar beak ligament with 3 mm bur - Split FCR in ½. Route ½ through tunnel, while distracting thumb in functional position, suture split FCR to itself, then anchovie it with weave stitch, multiple looping stitches. Anchovie the other ½. Place both in space (no need to suture) and close capsule, close skin. -PCP 1st to 2nd metacarpals. a. Other treatments: stage I: Eaton/Littler volar ligament reconstruction. Stage II: Eaton single interposition, Thompson suspensionplasty, metacarpal osteotomy. Stage III: Eaton double interposition, Thompson, simple trapeziectomy in low demand elderly patient without subluxation. Limited indication for silicone arthroplasty: RA. TJA with metal/polyethylene. a. MCP hyperextension: <30 degrees(may pin and move EPB from PP to MC. >30 degrees(arthrodesis or volar capsulodesis. WRIST 6) Scaphoid excision and replacement

a. Since 1985, Swanson used titanium scaphoid implant, sutures from implant to lunate, add LC or LTq fusion to shield implant. 7) Lunate excision and replacement a. Titianium. Sutures through scaphoid and Tq, add STT or SC fusion. 8) Proximal row carpectomy (PRC). Indications: RC arthrosis (Kienbock‘s, SL dissociation, failed Silastic implant, scaphoid nonunion, RA, spastic wrist contractures) Need intact capitate proximal pole and lunate fossa. TECHNIQUE: straight longitudinal incision, open 3rd compartment. Transverse capsulotomy at RC joint, T distally. Excise FULLY S, L, Tq (will impinge if leave some bone), may need 0.062 threaded K-wire as joystick. Preserve volar capsule, especially RSC. SAC x 6 weeks. 9) RC- Swanson silicone elastomer, intramedullary stemmed, flexible-hinge implant, fills PRC space, supposed to add stability and prevent capitate-radius DJD. Usually for RA, young person, good bone stock, low demand, limited painful motion. Do not use if unstable soft tissues. TECHNIQUE: dorsal approach. Open 6th compartment, make 2 radially base flaps of retinaculum. Open capsule- distally based flap. Remove S & L, osteotomize C and Tq, ream, place implant, resect distal ulna, +/- cap, stabilize with part of retinaculum, close capsule, repair retinaculum, SAC 4-6 weeks. 10) DRUJ-authors do not usually cap, Swanson uses silicone for decrease bone overgrowth, improve cosmesis, and allow stabilization. 11) WRIST TOTAL JOINT REPLACEMENT: major indication: RA >50 year old patient. If 1 wrist and post-traumatic, fusion better. If bilateral, need motion in at least 1 wrist. Authors developed prosthesis, transverse oriented, ellipsoid, semi-constrained with porous coating. No cement in radius, use in distal component. See surgical techniques. Can revise to RC arthrodesis if fails--use large iliac crest block to fit space and plate. Chapter 8 - Wrist arthroscopy: 1 (Gary Poehling, David Ruch) INDICATIONS: 1) DX for unexplained wrist pain despite 3 months of conservative RX 2) RX mechanical symptoms of TFCC tears and interosseous ligament injuries, 3) debridement loose bodies, chondral lesions, synovitis, 4) assist in reduction/fixation of DRF and carpal instabilities, 5) RX ulnar impaction with TFCC and LTq debridement, wafer, 6) resection DWG Wrist arthroscopy technique 1. Supine, shoulder and elbow each 90 degrees 2. finger traps digs 2,3, 7-10 pounds traction, wrist 15-20 degrees palmar flexion 3. 18 g needle to 3-4 portal, 1 cm distal to Lister‘s. Follow 12 degree palmar tilt of distal radius. Inject 5-7 cc NS, get backflow. 4. Make 3-4 portal (can see 70% RC joint): 11 blade through skin, spread, enter with hemostat, blunt trocar/sheath, camera (1.7-3.0 mm, 30 degrees). Either gravity inflow and 18 g needle outflow, or pump. 5. Assess bone: radial styloid, radius, scaphoid, lunate. Assess soft tissue: SLIO, RSC, LRL, RSL=ligament of Testut=NV bundle to SLIO, SRL, TFC 6. Make 6-R (immediately radial to ECU) portal under direct vision with 18 g 1st. (be more distal than 3-4 to avoid TFCC injury). May use for outflow, instrument, camera. 7. Through 6-R, can see: lunate, triquetrum, LTIO, TFCC, UL & UT ligaments, prestyloid recess, pisotriquetral space

8. 4-5 portal (between EDC & EDQ) 9. MIDCARPAL: MCR-18 g needle, place 1 cm distal to 3-4 portal in line with radial margin of 3rd MC, inject 3-5 cc. Enter with slight palmar tilt (between S&C). Evaluate STT distally; can see SL articulation, proximal pole capitate, SC & LT joints 10. MCU - 18 g 1 cm distal to 4-5, in line with 4th MC (see LT, CH joints) 11.DRUJ – proximal portal just proximal to sigmoid notch of radius. Supinate. Evaluate sigmoid notch, ulnar head, TFCC margin. Distal portal – assess undersurface TFCC, UC ligaments origins, ulnar head 12.MAJOR COMPLICATIONS: injury to dorsal sensory branches ulnar and radial nerves and radial artery (1-2, STT portals) 13.Post-op: portals not closed. Splinted in 20 degrees extension, MCP free; d/c at 1 week. ADL‘s at 2 weeks, full recovery at 6 weeks. Other portals: 1-2 (3mm from radial sensory nerve and radial artery-limits use), STT, 6-U(close to dorsal branch ulnar nerve), Tq-H Chapter 9 - Wrist arthroscopy: 2 (Gary Poehling, David Ruch) LIGAMENTOUS INSTABILITY Arthroscopy indicated if 1) dynamic instability suspected but cannot confirm radiographically, 2) partial interosseous ligament injury suspected 3) unexplained mechanical symptoms RX: 1) Partial SL tear (central fibrocartilage flap tear, intact dorsal & palmar components) RX: resect torn central portion of ligament. Re-evaluate for instability, specifically: dorsal SL component, dorsal capsule attachment (sweep dorsally from SLIL to view capsular attachment to scaphoid and SLIL-may need ulnar viewing portal), midcarpal joint

congruity 2) Complete SL tear (all 3 components SL torn, dorsal capsule attachment SL intact, DRC attachment to lunate intact (sweep dorsally from lunate to view DRC attachment to lunate-may need ulnar viewing portal)) RX: resect torn central portion of ligament. Re-evaluate for instability, specifically: dorsal capsule, DRC ligament. 3) Complete SL tear + dorsal capsule tear - dynamic instability usually present (UMC portal demonstrates palmar flexed scaphoid, probe reveals gross instability between S & L) RX: open SL ligament repair & reattachment of dorsal capsule. 4) Complete SL tear + dorsal capsule tear + DRC ligament tear (UMC portal demonstrates palmar flexed scaphoid & dorsiflexed lunate, scope passes easily through SL from RC to MC joints) RX: SL ligament repair & reattach DRC to lunate. 5) Partial LTq tear (intact UC ligaments, intact DRC) RX: debride central fibrocartilage 6) Complete LTq tear + UC ligament tear (intact DRC) RX: debride LTq and UC ligaments 7) Complete LTq tear + UC ligament tear + DRC tear (incongruous LTq interval from RMC) RX: open dorsal capsulodesis with suture anchors in L & Tq with pinning LTq x 6 weeks (APM) vs. limited intercarpal fusion

Chapter 10 - Wrist arthroscopy: 3 (A. Lee Osterman) OPERATIVE PROCEDURES SYNOVIAL BIOPSY -RA, PVNS, infection, gout, pseudogout, sarcoidosis, etc. SYNOVECTOMY -RA (complete synovectomy, to include DRUJ; should have active synovitis that has failed medical RX, and joint space preservation-less that Larsen Stage III) -septic wrist CHONDRAL LESIONS -similar principles as in other joints TFCC TEARS -HX: ulnar wrist pain, click, h/o fall, traction, twist -PE: tender TFCC, TFC cx test (axially load wrist and ulnar deviate and rotate( reproduces sxms and click), check for DRUJ instability (―piano key‖ sign) and DRUJ shuck, LTq palpation for tenderness and LTq shuck, check for ECU subluxation, check grip strength with Jamar dynamometer. Consider differential selective injections. -STUDIES: xrays, MRI (90% accurate), arthrography (high incidence positive findings in asymptomatic wrists-less used)(Mikic: no tears < 30 y.o., linear progression after until all over 50 y.o. with tear), CT (to assess DRUJ instability) -DDX ulnar wrist pain: TFCC tear, ECU subluxation, LTq injury, PTq OA, chondral lesion of lunate, ulnar artery thrombosis, ulnar neuropathy -TFCC blood supply: radiocarpal branches of ulnar artery and dorsal and palmar branches of anterior interosseous artery. Peripheral 10-40%. -RX: For acute injury, R/O DRUJ instability and ECU subluxation. If negative, then immobilize 4 weeks, then rest, rehab, NSAIDs. Scope if no better and interfere with activities after 3 months of non-operative RX. PALMER CLASSIFICATION: Type I=traumatic. Type II-degenerative TYPE I - TRAUMATIC 1. IA: central, several mm from radius, usually volar-dorsal, unstable flap 2. IB: peripheral tear from ulna (with or without bony fragment). May be associated with ECU sheath disruption and ECU subluxation, mild DRUJ instability 3. IC: disruption from volar UC extrinsic ligaments. May result in supination deformity of carpus on ulna 4. ID: avulsion from sigmoid notch, usually linear (volar-dorsal) often with DRF Scope RX:

1. IA: debride with shaver (2.0-3.0mm) in 6R (scope in 3-4). Can take up to 2/3 and avoid peripheral 2 mm. 80-85% good-excellent results 2. IB: pathognomic finding-loss of normal tension TFCC (should be taut like drumhead, not soft like feather bed). 50% with ECU subluxation; if positive, need open ECU sheath recon. To repair TFCC, shave tear edges/synovium to get bleeding. 1 cm incision just radial to ECU, open sheath, retract ECU ulnarly, pass 2 needles out(in. Wire loop in 1, retrieve 2-0 PDS through other, tie over capsule (may need to repeat. Munster cast x 4 weeks. 85-90% good-excellent results. If with bony styloid fragment, either ORIF or excise and reattach TFC to

ulna 3. IC: loss of tension ulnar extrinsic ligaments and see PT joint. 1 cm incision volar to ECU, out(repair (like IB). If large, open and may augment with FCU strip 4. ID: roughen/burr sigmoid notch and sutures through bony tunnels in DR or K-wires and leave 4 weeks, cast type II-degenerative TFC lesions (ulnocarpal impaction syndrome) -if ulnar neutral or positive, 73% TFCC tears/perforations vs. 17% if negative (Viegas, JHS, ‘87) -see Ch 30, ulnar impaction syndrome for DX a) Palmer classification: IIA: wearing of TFC without perforation or chondromalacia IIB: wearing of TFC with chondromalacia of lunate or ulna IIC: TFC perforation with chondromalacia of lunate or ulna IID: TFC perforation with chondromalacia of lunate or ulna and LTq tear (but no carpal instability) IIE: like IID, but with ulnocarpal OA b) RX: scope-TFC lesion usually central and ragged. Assess chondral surfaces. Assess LTq. IIA & B: debride synovial inflammation and open ulnar shortening osteotomy IIC: debride tear and either open ulnar shortening osteotomy or Feldon wafer procedure. IID & E: debride synovial inflammation, then assess stability of LTq from RC and midcarpal portals. If no LTq stepoff and no chondromalacia hamate, then wafer APM. If evidence of instability, then ulnar shortening APM. If still significant LTq instability, PC K-wire LTq with 23 0.045s and bury SQ. SAC 4-8 weeks, d/c pins 6-8 weeks. -Outcome for type II lesions at 3-5 years, 75% good-excellent FELDON WAFER PROCEDURE: 3-4 viewing portal, 4 mm bur through ulnar portal. Pronate and supinate, use medial corner radius as landmark. Resection limit 3-4 mm. After radial 1/3 ulna resected, place 18 g needle in DRUJ beneath tear and establish portal to use bur or 1/8 inch osteotome to level remaining ulna. Use fluoro to assess. Post op- 4weeks SA splint. CARPAL INSTABILITY (see previous chapter) FRACTURES/ASSOCIATED INJURIES -DRF: may aid in intra-articular fxs, or if suspected carpal ligamentous injury. Use tower, or place horizontally slightly flexed with sterile finger traps on digs 1-3 and weight over end of

table (APM), or use ex-fix as traction. Dorsal punches can be lifted with Freer through small incision over 4th compartment, bone grafted with ICBG or bone graft from proximal ulna or bone graft substitute. Volar lunate fragments may need small buttress plate (2.7 mm condylar) placed through limited incision between finger flexors and ulnar NV bundle. -ASSOCIATED INJURIES TO DRF: (Geissler JBJS ‘96 -60 pts with displaced DRF with 43% TFC lesions, 32% SLIL tears, 15% LTq tears, chondral injuries 20-40%). -SCAPHOID FXS: ―pioneered by Whipple, it is one of most demanding arthroscopic procedures.‖ DWG -40% success with aspiration-with or without cortisone (Richman JHS ‘87). TECHNIQUE: Scope in 6-R or 4-5 and look to dorsum SLIL, see synovitis, see stalk in 2/3. Place needle through ganglion to rupture it down to stalk. Make ganglion portal (usually 3-4) and resect (shave or punch) a 1 cm area of dorsal capsule in area of stalk. Recurrence < 1% (vs. 2-40% in open). May consider for occult ganglions. CONTRACTURE RELEASE -contracture after DRF, ligamentous inj, DWG excision, late RSD. TECHNIQUE: 3-4 and 6-R portals. Trochar clears path. Freer or banana blade to incise adhesions. Some release of dorsal capsule, but do not release intrinsic or volar extrinsic ligaments. Gentle PROM intraop. SALVAGE PROCEDURES -RADIAL STYLOIDECTOMY-for SLAC/SNAC wrist (stage I). TECHNIQUE: view 3-4, 3 or 4 mm burr in 1-2 portal to resect styloid at level of RSC ligament. Preserve volar ligaments. Check resection by fluoro with radial deviation to assure no impingement. -PRC- for SLAC/SNAC wrist and preserve proximal pole capitate and lunate fossa. SMALL JOINT ARTHROSCOPY-thumb CMC for Bennet‘s fx, synovitis, stable degenerative or post-traumatic OA. TECHNIQUE: thumb traction with tower. Portals

just dorsal and volar to APL. Infuse 2cc NS, 2.0 or 2.9 mm scope, 1.9mm shaver. COMPLICATIONS OF WRIST ARTHROSCOPY – RSD (3.7%), sensory branch neurapraxia (2.3%), tendon problems (0.9%). Chapter 11 – Elbow Arthroscopy: Anatomy and Diagnosis (Gary Poehling, Ranjit Gill, David Ruch) added some Chapter 12 1) Neurovascular Structures: most at risk: radial (most common) and median nn., brachial a. Brachialis separates NV structures from joint 2) 2 elbow compartments: anterior and posterior

3) INDICATIONS: loose bodies, OA, articular cartilage defects, OCD, AVN, RA (synovectomy), PVNS, synovial chondromatosis, septic joint, debridement of osteophytes, adhesions, symptomatic lateral synovial plicae, undiagnosed pain with clinical or radiographic abnormalities, painful mechanical symptoms (snap, click, lock, clunk), contracture, instability, fractures, radial head excision 4) CONTRAINDICATIONS: prior ulnar n. transposition, RSD, severe ankylosis 5) OR setup: prone or lateral, +/- tourniquet, narrow bump for arm, pump (up to 80-100 mm Hg), elbow at 90 degrees; distend joint with 15-30 ml thru soft spot. 4mm scope for anterior, 2.7mm for posterior, or 4mm for both; use sheath specifically designed for 30 degree to prevent flow into soft tissue. 6) PORTALS: 3 anterior, 4 posterior a. Anterior: i. Proximal medial: 1st portal. Incise 2 cm prox to medial epicondyle and anterior to intermuscular septum, enter and stay on anterior humerus. i. Anterolateral: inside-out from PM portal at anterior RC joint. i. Proximal lateral: 2 cm prox to lateral epicondyle and on anterior margin of humerus a. Posterior: i. Midlateral (=soft spot. No significant NV structures): main viewing portal for posterior compartment. Between olecranon and radial head. i. Adjacent : parallel to midlateral portal. i. Posterior lateral: lateral to triceps at level of olecranon tip. Best for olecranon fossa and lateral olecranon. i. Straight posterior = trans-triceps: 2 cm prox to olecranon tip thru center of triceps. Ideal for medial olecranon and fossa Chapter 12 – Operative Elbow Arthroscopy Part 1: Loose Bodies and Synovial Conditions (Shawn O‘Driscoll) -Most common use: loose body (LB) removal -30% LB not seen on x-ray -16% population with subluxing ulnar n. – evaluate pre-op. proximal medial portal at risk. COMPLICATIONS: -fewer than 10%: iatrogenic cartilage damage, tourniquet complication, nerve injury, stiffness, persistent portal drainage TIPS: -Wrap forearm with ace within 1 cm of portals. This limits elbow swelling since diffuses after release. -Quick scope switch by placement switching stick and sheath on other end -Large loose bodies pushed out with scope cannula after retract camera slightly -For OA, remove osteophytes as well as loose bodies -Work fast (swelling) -Shut off shaver suction near nerves - posteromedial gutter (ulnar nerve) and anterolateral joint (radial nerve)

-Use retractor in anterior compartment -Immediate FROM post-op Part 2: Cartilage lesions, osteoarthritis, and contracture (Felix Savoie III, Larry Field) CHONDROMALACIA: -Symptoms: pain , swelling, crepitation, motion loss (especially extension and supination) , locking, giving way. -PE: crepitation, compression test -Due to overuse like baseball or gymnastics -Most commonly at radiocapitellar joint, then posterior olecranon fossa. -NONOPERATIVE TREATMENT: rest, NSAIDS, rehab, hinged brace -OPERATIVE MANAGEMENT: debride to stable rim. Look especially at RC joint and olecranon tip and fossa. Full-thickness cartilage loss abraded or drilled. OSTEOCHONDRITIS DISSECANS: -Caused by interruption in blood supply to area of bone and cartilage. -More common in teens, but can occur at any age in response to over-stress -Most commonly in capitellum, but can occur at any place in elbow -Symptoms: pain, swelling, motion loss (especially extension) -Radiology: occasionally seen on x-ray, but MRI shows best (get MRI if suspect) - NONOPERATIVE TREATMENT: hinged brace set at pain-free arc of motion, NSAIDS. Monitor healing by serial x-ray or MRI -OPERATIVE MANAGEMENT: done primarily if MRI shows loss of articular cartilage cap or fragmentation. Done secondarily if fail nonoperative RX. TECHNIQUE: Debride 1st. HerbertWhipple cannulated screw or absorbable pin to repair if sufficient bone on fragment, otherwise remove fragment. Postop: immediate ROM. Hinged brace 3-6 weeks if repaired. OA: -Middle aged patient, usually male -Symptoms: slowly decreasing ROM (at extremes of F/E), pain with activity, morning stiffness -NONOPERATIVE TREATMENT: rehab, NSAIDS. -OPERATIVE MANAGEMENT: Open vs. arthroscopic debridement, especially radial head, coronoid, olecranon tip and fossa, gutters (no suction medially-ulnar nerve). Consider ulnohumeral arthroplasty (Outerbridge-Kashiwagi or olecranon fossa fenestration procedure): Pilot hole drilled through posterocentral portal through center of olecranon fossa and enlarged to at least 1 cm. CONTRACTURE: (also see Chapter 22) -Etiologies: fractures, dislocations, arthritis, head injury, burns, neurologic injury. -Either intrinsic (intra-articular)-joint incongruity, post-traumatic arthritis, ankylosis, loose bodies, synovitis; or extrinsic (extra-articular)-capsular contracture or scar, collateral ligament tightness, musculotendinous contracture, HO. -NONOPERATIVE TREATMENT: rehab, bracing

-OPERATIVE TREATMENT: Open vs. arthroscopic. Arthroscopic is challenging—not much space; higher chance of nerve injury. Capsule released from humerus at cornoid fossa and proximal 1-2 cm. Deepen olecanon fossa; possibly perform ulnohumeral arthroplasty.

-CP = irreversible, static, perinatal brain injury, with variable decrease in motor function, sensibility, and intelligence -CLASSIFICATION: 1) Number of limbs involved: monoplegia (1 extremity), hemiplegia (1 arm, 1 leg), paraplegia (2 legs), quadriplegia (4 extremities). 2) Motor involvement: spastic, flaccid, athetotic -Upper extremity spastic deformity: shoulder internal rotation, elbow flexion, forearm pronation, wrist flexion, finger flexion, intrinsic spasticity, thumb-in-palm. -CP usually noted by 1 year of age PATIENT EVALUATION HISTORY -Team approach (pediatrician, OT/PT, social worker) -Rule out other treatable diagnoses of cerebral dysfunction -Ask parents what they notice are problems, activities/functions the child cannot perform PHYSICAL EXAM -Observe child: activity, intelligence, position of rest of extremities -Ask child to grasp object (pen) -Measure A & PROM -Volkman’s Angle: Flex wrist and extend digits, then extend wrist while keeping digits extended. If cannot extend wrist to neutral, difference to neutral = Volkman‘s Angle; indicates flexor tendon tightness; requires surgery. -Differentiate between spasticity and contracture -Measure strength of various muscle groups for possible transfer -Grading of hand function: 1) Poor: absent/poor grasp & release, poor control, 2) Fair: helping hand in rudimentary functions, 3) Good: helping hand for dressing, eating, 4) Excellent: independent use in dressing, eating -Inspect potential hygiene problems areas STUDIES -Dynamic EMGs may help identifying spastic/flaccid muscles and if they are firing in phase; controversial whether they add more to frequent physical examinations -Continuous activity in a muscle is not an absolute contraindication for use as a transfer, since some data suggests that some phasic activity can develop after transfer. TREATMENT NON-OPERATIVE -ROM can help prevent contractures -Splinting/serial casting can stretch tight muscles, but results usually temporary OPERATIVE -Surgery is reparative, not curative; limb will rarely be normal

-3 main indications for surgery: improve function, hygiene, cosmesis -Guidelines: Hygiene is primary goal if IQ < 50, hand placement (from head to knee) > 5 seconds, and poor sensibility. Cosmesis additional goal if IQ > 50, but poor placement and sensibility. If IQ > 50, hand placement < 5 seconds, and good sensibility, then functional improvement is goal. -Patients with little voluntary control will not benefit from surgery from a functional standpoint -Timing: Delay until clear evaluation of functional use of hand (between 6-12 years old) SPECIFIC OPERATIVE ISSUES SHOULDER -Typical posturing is internal rotation and adduction caused by spastic subscapularis and pectoralis major. Much less frequently, external rotation and abduction posturing (from supraand infraspinatus and teres minor) -For internal rotation, adduction posture with hygiene problems, consider subscapularis and pectoralis major lengthening or release. Do not perform if subluxed/dislocated GH joint (consider arthrodesis in that case). Occasionally a proximal humerus external rotation osteotomy is needed. RELEASE OF SHOULDER INTERNAL ROTATION DEFORMITY – TECHNIQUE -Deltopectoral approach. Identify insertions of subscapularis and pectoralis major. Z-lengthen if possible; release if not. Post-op: external rotation abduction splint x 3 weeks. ELBOW CONDITION -Deformity is flexion caused by spastic biceps, brachialis, brachioradialis, and contractures if long standing -Can cause skin breakdown in antecubital fossa, dressing problems. Can limit wheelchair transfers, crutch use, 2-handed object manipulation, and keyboard use. OPERATIVE PROCEDURES - INDICATIONS: 45 degrees in functional extremity, 100 degrees for wheelchair bound patient or hygiene issues. -2 types of surgery: 1) Lengthen/release muscles, 2) Denervate muscles -ELBOW FLEXOR LENGTHEN/RELEASE: Lengthening biceps, brachialis, and brachioradialis can increase extension 40 degrees with minimal loss of flexion power. SURGICAL TECHNIQUE: S-shaped antecubital incision. Transect Lacertus Fibrosus. Identify lateral antebrachial cutaneous nerve lateral to biceps, between biceps and brachialis, mobilize and retract laterally. Identify and protect neurovascular bundle medial to biceps. Address biceps: If mild condition, then fractional lengthen (2 transverse and slightly oblique cuts in tendinous portion at musculotendinous junction). If severe, then Z-lengthen with as long limbs as possible. Address brachialis: fractional lengthening; however, myotomy frequently necessary. Address brachioradialis: may need to release origin from the distal humerus. Identify and protect the radial nerve between the brachioradialis and brachialis. Address anterior capsule by releasing if needed. Repair biceps Z-lengthen with elbow at 30-45 degrees flexion (Pulvertaft weave). Post-

operatively, immobilized in 30-45 degrees x 1 month, then removable splint x 1 month with A & PROM several x‘s/day. Consider nighttime splint if recurrence tendency. -MUSCULOCUTANEOUS NEURECTOMY: For deformity < 30 degrees. Full PROM mandatory. Preoperative assessment with lidocaine block of musculocutaneous nerve along medial proximal biceps may help differentiate spasticity from contracture. SURGICAL TECHNIQUE: Expose musculocutaneous nerve through an axillary approach. Identify it as it penetrates the biceps; can stimulate to confirm. Transect after confirmation. FOREARM CONDITION -Pronation deformity by spasticity of pronator teres and pronator quadratus. -Functional deficit: palms cannot face each other; 2-handed object manipulation impossible OPERATIVE PROCEDURES: -Procedures to improve wrist extension can also improve supination. (FCU to ECRB increases supination 22 degrees) FLEXOR-PRONATOR SLIDE INDICATIONS: Contractures of pronator teres, elbow, long flexors of wrist and digits. Hygiene issues. Gross release; not able to fine tune. CONTRAINDICATIONS: When fine tuning needed. Weak finger flexors (slide will weaken more) SURGICAL TECHNIQUE: Skin incision form 5 cm proximal to medial epicondyle to ulnar mid forearm. Identify and protect ulnar nerve and branches to FCU. Divide lacertus fibrosus and identify and protect median nerve and brachial artery. Dissect flexor-pronator mass en masses from the medial epicondyle, ulna, and interosseous membrane while protecting the MCL. Release the FPL from the radius. Extend wrist and digits and release flexors as needed. May transpose ulnar nerve before closure. Immobilize 4 weeks with elbow extended 45 degrees, supination, wrist 30 degrees extended; then removable splint x 4 weeks. PRONATOR INSERTION RELEASE INDICATIONS: No voluntary control of pronation and have good active supination. CONTRAINDICATIONS: No active supination. SURGICAL TECHNIQUE: Palpate pronator teres insertion on mid aspect radius with forearm in maximal supination; make 3 cm longitudinal incision over this. Identify and protect lateral antebrachial cutaneous nerve and superficial radial nerve. Dissect between BR and ECRL, identify and transect pronator teres, passively supinate. Immobilize in neutral x 4 weeks, then removable splint x 4 weeks. PRONATOR TERES RE-ROUTING INDICATIONS: Active control of pronator and lacking active supination CONTRAINDICATIONS: No active pronation SURGICAL TECHNIQUE: Approach as in PT release (see above). Release pronator insertion with distal strip of periosteum. Interosseous membrane dissected off radius for 5 cm proximal to insertion site. Pass the tendon through the interosseous membrane along ulnar border of radius in volar to dorsal direction and reattach to radius on lateral aspect with forearm in 45 degrees

supination. Fix through bony tunnel (1.6 mm hole through, 2.8 mm hole in proximal cortex, pass sutures out small hole and suture it to the tendon) or suture anchor or Z-lengthen pronator and pass distally attached portion around radius from dorsal to volar through interosseous membrane and reattach to proximal tendon. Immobilize elbow in 90 degrees flexion and 45 degrees supination x 4 weeks, then removable splint x 4 weeks. -Pronator rerouting with increase in active supination 46-78 degrees vs 54 degrees in pronator tenotomy -Do not release pronator quadratus when performing pronator release or rerouting (may lose pronation) WRIST AND DIGITAL EXTENSION CONDITION: -Absence of wrist extension can have several causes: 1) weak wrist extensors, 2) tight or spastic wrist flexors, 3) volar wrist capsular contracture. -Flexed wrist has 2 functional problems: 1) decreases mechanical advantage of digital flexors, thus weakening grip, 2) places hand in position where fingers are obstructed from visual feedback -Consider median and ulnar nerve blocks at the elbow to eliminate flexor spasticity to better evaluate wrist extension -Imperative to evaluate digital extension with wrist extension to ensure that increased wrist extension does not significantly decrease digital extension OPERATIVE PROCEDURES -If severe wrist capsular contracture, PRC may help increase passive wrist extension, then tendon transfers can be performed. FCU TO ECRB TRANSFER INDICATIONS: Tight FCU and absent or weak wrist extension (<neutral) CONTRAINDICATIONS: Absence of FCR (If transfer FCU with absent FCR, may lose wrist flexion) SURGICAL TECHNIQUE: Harvest FCU either through long volar incision or 2 transverse ones. Transect FCU at its insertion on the pisiform and mobilize it while protecting the ulnar NV bundle. Put tension on the distal end to palpate the proximal end and make incision at this point. Pass FCU over ulna dorsally deep to SQ fat, nerves, and veins, but superficial to tendons. With wrist in neutral to slight extension and maximal tension on tendon ends, Pulvertaft weave into ECRB. If passive wrist flexion to 20 degrees is not possible, then transfer is too tight. Ensure that weave will not encroach on 1st dorsal compartment intersection or extensor retinaculum. Immobilize with wrist extended 30 degrees and neutral rotation x 4 weeks, then removable splint x 4 weeks. ECU TO ECRB TRANSFER INDICATIONS: Active extension present to neutral, usually with ulnar deviation, but active digital flexion forces wrist into flexion CONTRAINDICATIONS: No active extension, or if extension of wrist precludes digital extension

SURGICAL TECHNIQUE: Approach through single longitudinal midline incision or multiple transverse ones. Transect insertion of ECU from 5th metacarpal base, mobilize, and transfer to ECRB as in FCU to ECRB transfer (see above). Fractionally lengthen FCU. FCU TO EDC TRANSFER INDICATIONS: weak wrist and digital extension (rare to have both) CONTRAINDICATIONS: good digital extension and weak wrist extension SURGICAL TECHNIQUE: Harvest FCU as above. Weave through EDC tendons x 2 with MP joints in full extension with wrist neutral. Immobilize wrist in 30 degrees extension, digits fully extended, slight supination x 4 weeks; removable splint x 4 weeks. PT TO ECRB TRANSFER INDICATIONS: when FCU transfer not advised secondary to non-functioning FCR. Also can be used when FCU being transferred to EDC, but also need to augment wrist extension. CONTRAINDICATIONS: If patient needs wrist flexion for digital extension (may overtighten) SURGICAL TECHNIQUE: Use same approach is in PT rerouting. Keep PT as long as possible, with periosteum. Pulvertaft weave into ECRB. See FCU to ECRB for tensioning and post-op protocol. Fractionally lengthen FCU. BR TO ECRB TRANSFER INDICATIONS: when no other motors available SURGICAL TECHNIQUE: Approach through 1 longitudinal incision or multiple transverse ones. Release BR insertion with long periosteal extension. Mobilize proximally. Transfer to ECRB as above. EPIPHYSEAL WRIST ARTHRODESIS INDICATIONS: For hygiene or cosmesis in hand with little or no function. CONTRAINDICATIONS: Functional hand, since arthrodesis decreases tenodesis wrist effect. SURGICAL TECHNIQUE: Wrist approached dorsally, articular surfaces of scaphoid, lunate, and distal radius removed with knife to bone, while protecting physis. Fix with smooth Kirschner wires. WRIST AND DIGITAL FLEXOR TENDON TIGHTNESS OPERATIVE PROCEDURES: Fractional lengthening weakens the least, then Z-lengthening. STP lengthens the most, but also weakens the most. Its use is for the non-functional hand. FLEXOR-PRONATOR SLIDE (See Forearm Section) TENDON FRACTIONAL LENGTHENING INDICATIONS: Functional hand CONTRAINDICATIONS: If digits cannot be fully extended with wrist flexed, then fractional lengthening will not produce enough length SURGICAL TECHNIQUE: Expose musculotendinous junction. 2 slightly oblique tenotomies with distal one at least 2 cm proximal to end of junction and at least 1 cm apart. Only cut tendon and not muscle. Extend digits to slightly less than full extension with wrist extended. Immobilize

wrist in neutral x 4 weeks, instruct in immediate digital exercise. Then removable wrist splint x 4 weeks. TENDON Z-LENGTHENING INDICATIONS: For FPL and wrist flexors that are tight, even with wrist flexed, where fractional lengthening will not be enough. For FPL, amount lengthened is 0.5 mm / degree. CONTRAINDICATIONS: Z-lengthening not used for finger flexors, since STP equally effective and less tedious (see below) SURGICAL TECHNIQUE: Longitudinal incision over tendon. Long longitudinal cut in tendon and step cut. Repair ends side-to-side or Pulvertaft. For wrist, tension set at neutral wrist. For FPL tension set at neutral wrist and slight MP & IP flexion; with wrist extension, thumb should cross index finger and with wrist flexion, thumb should be able to be fully extended out of palm. Immobilize wrist in slight flexion, thumb neutral x 4 weeks. Then removable splint x 4 weeks. SUPERFICIALIS TO PROFUNDUS TRANSFER (STP) INDICATIONS: When fingers cannot be passively extended, even with wrist fully flexed. CONTRAINDICATIONS: Functional hand, since STP will significantly weaken grip SURGICAL TECHNIQUE: Transect FDS distally, FDP proximally. Suture tendons individually if digital function, together if no function. Tension at neutral wrist and 45 degrees at MP and PIP joints. Test: extend wrist 45 degrees; digits should touch palm. With wrist flexion, digits should be extend completely. Immobilize wrist neutral, MP 90 degrees, PIP 0 x 4 weeks, then removable splint x 4 weeks. PRC / WRIST ARTHRODESIS INDICATIONS: When release of all digital and wrist flexors is necessary to return wrist to neutral. Indicated for hygiene or cosmesis. CONTRAINDICATIONS: Functional hand

THUMB IN PALM DEFORMITY -Greatest deterrent to good hand function -4 possible issues: 1) Spastic thumb adductors and flexors, 2) flaccid thumb abductors and extensors, 3) hypermobile MP joint, 4) 1st web space contracture. CLASSIFICATION (House): Type I: Simple adduction (spastic adductor and 1st dorsal interosseous), Type II: Adduction and MP flexion (added spastic FPB), Type III: Adduction and MP hyperextension (added spastic EPB, not FPB), Type IV: Adduction, MP & IP flexion (added spastic FPL) -Only consider surgery if other digits are functional OPERATIVE PROCEDURES PROCEDURES FOR SPASTIC THUMB INTRINSICS RELEASE OF ORIGIN OF SPASTIC THUMB INTRINSICS -Indicated for Type I (FPB not involved) -Through a web space incision, expose the adductor pollicis between the common digital NV bundle to the index and long fingers and the flexor tendons. Release the adductor pollicis origin

off of the 3rd metacarpal, protecting the deep and superficial arches and the motor branch of ulnar nerve. Release the 1st dorsal interosseous off of the 2nd metacarpal, protecting the princeps pollicis vessels. RELEASE OF INSERTION OF SPASTIC THUMB INTRINSICS -Indicated for Type II (FPB involved) -Through a web space incision, release the insertions of adductor pollicis, 1st dorsal interosseous, and FPB. PROCEDURES FOR FLACCID THUMB ABDUCTORS/EXTENSORS EPL REROUTING -Indicated for flaccid thumb abductors and extensors. EPL must be functional. -The EPL is exposed through a longitudinal incision at the base of the proximal phalanx and transected with a 10 x 4 mm strip of extensor aponeurosis. Make a second transverse incision just proximal to the extensor retinaculum over the EPL and pull the EPL out of this wound. Pass a hemostat from the thumb incision, through the 1st dorsal compartment, and out the 2nd incision (a 3rd incision over the 1st dorsal compartment may be needed). Draw the EPL through the 1st dorsal compartment, along the radial border of the APL and out the thumb wound, suture it to the radial aspect of the base of the thumb proximal phalanx. If the MP is hyperextensible, then either suture the EPL to the metacarpal or fuse the MP. IMBRICATION OF APL AND EPB - Indicated for flaccid thumb abductors and extensors, and EPL non-functional. -Skin incision is made over 1st dorsal compartment and retinaculum is opened. APL and EPB are plicated with hemostat and sutured. FPL ABDUCTORPLASTY -Indicated for flaccid thumb abductors and extensors, EPL is non-functional and the FPL is spastic. -Make a radial midlateral incision on the thumb from the middle of the distal phalanx to the neck of the 1st metacarpal. Transect the FPL opposite the proximal phalanx. Make a 2nd incision (longitudinal at the volar wrist) just radial to the FCR and identify and withdraw the FPL. Pass a hemostat from the thumb wound to the wrist wound and pass the FPL. Attach the FPL to the radial aspect of the base of the proximal phalanx. Tenodese the IP with the distal stump of the FPL, either by suturing it to the proximal phalanx or by passing it through a bony tunnel in the proximal phalanx and tying it over a button. PROCEDURE FOR HYPERMOBILE MP MP EPIPHYSEAL ARTHRODESIS -Indicated if MP hyperextensible and tendon transfers planned to augment abduction/extension. -Approach MP though dorsal longitudinal incision between EPL and EPB. Subperiosteally dissect to the MP articular surface, taking care not to extend to the physes. Osteotomize with a microsagittal saw for 10 degree flexion. Hold with cross 0.035 inch K-wires. PROCEDURES FOR CONTRACTED WEB SPACE

OPTIONS: -Z-PLASTY -4-FLAP Z-PLASTY -FTSG -DORSAL ROTATION FLAP INTRINSIC MUSCLE SPASTICITY CONDITION -Intrinsic Plus positioning, swan-necking over time -Rarely a functional problem; only if PIP ―sticks‖ in hyperextension and patient has difficulty initiating digital flexion -MP flexion rarely functional problem, since EDC can usually overpower intrinsics TREATMENT NON- OPERATIVE -Figure-of-eight extension block splints OPERATIVE PROCEDURES INTEROSSEOUS MUSCLE SLIDE INDICATIONS: For significant MP flexion contracture decreasing function and/or interdigital hygiene. Retains some intrinsic function. SURGICAL TECHNIQUE: Transverse incision on dorsum of hand at mid-metacarpal level, or 2 longitudinal incisions in index-middle and ring-little interspaces. Subperiosteal dissection of both dorsal and volar interosseous muscles. MP joints fully extended with PIPs flexed. Immobilize MPs in full extension x 4 weeks (If MPs excessively tight, K-wire MPs extended x 4 weeks), then removable splint x 4 weeks. ULNAR MOTOR NEURECTOMY INDICATIONS: Hygiene is primary goal. Decreases intrinsic spasticity, but complete loss of intrinsic function. Test pre-op with ulnar nerve block at wrist. CONTRAINDICATIONS: Good digital function SURGICAL TECHNIQUE: Dissect Guyon‘s canal, ulnar nerve motor branch isolated and section excised. SUPERFICIALIS PIP TENODESIS INDICATIONS: PIP hyperextension that hinders active digital flexion CONTRAINDICATIONS: Paresis of FDPs SURGICAL TECHNIQUE: Mid-axial incision made over radial side of middle phalanx, flexor sheath incised. Identify radial slip of FDS. 2nd incision made over A1 pulley; incise A1. Radial slip of FDS identified and transected and withdrawn out distal incision (divide chiasm). 3rd midaxial incision made over ulnar aspect of proximal phalanx. Pass FDS slip from radial to ulnar incision (stay dorsal to FDP and NV bundles). Make transverse drill hole in distal 1/3 of proximal phalanx from ulnar to radial. K-wire PIP at 20 degrees flexion. Place suture in end of FDS slip and pass through drill hole from ulnar to radial with 2 Keith needles; exit out radial skin and tie over button. Alternatively, FDS can be fixed with a suture anchor on the ulnar aspect of

the proximal phalanx, or sutured to ulnar aspect of A2 pulley. Remove K-wire at 2 weeks and allow gentle motion with 20 degree extension block splint.

-Both exhibit upper motoneuron syndromes: impairment of motor control, spasticity, and stereotypic patterns of movement (hemiballismus, athetosis, tremor, cerebellar ataxia) STROKE -Pathophysiology: Interruption of oxygenation to neurons by thrombosis (75%), emboli (10%), or hemorrhage (15%). -Middle cerebral artery most commonly effected: upper extremity, face, speech. Majority of stroke patients have hemiplegia with nonfunctional upper extremity and lower limb with greater potential for function. Anterior cerebral artery: lower extremity. Posterior cerebral artery: visual cortex. -Important to evaluate cognitive impairment / rehabilitation potential -Clinical motor course: Flaccid paralysis from 24 hours to several weeks. Increasing muscle tone usually evident 48 hours after stroke. Voluntary movement returns in proximal muscles. Spontaneous neurologic recovery occurs primarily in the first 6 months; after 6 months, the patient is neurologically stable and definitive operative decisions can then be made. TRAUMATIC BRAIN INJURY -MVC is most common etiology -GLASCOW COMA SCALE: Eye opening: spontaneous 4, speech 3, pain 2, none 1. Motor response: obeys 6, localizes 5, withdrawal 4, abnormal flexion 3, extension 2, none 1. Verbal response: oriented 5, confused 4, inappropriate 3, incomprehensible 2, none 1. >11/15 with 82% moderate to good neurologic recovery. Under 20 years of age with better recovery. Less than 2 weeks coma with better recovery. -3 time phases: 1) acute injury, 2) physiologic recovery (6-18 months), 3) functional adaptation to residual deficits -HETEROTOPIC OSSIFICATION = intense inflammatory joint reaction with redness, warmth, pain, decreased ROM. 11% incidence with TBI. Most common at hips, followed by shoulder and elbow. Usually within 2 months of TBI. Incidence 85% with concomitant musculoskeletal injury. May be prophylactically treated with indomethicin (50 mg TID x 3 months), radiation (800 cGy x 1 dose), disphosphonate (Didronel). Early HO excision if threatening joint ankylosis or progressive nerve or vascular compromise. -HO in shoulder: Appears inferomedially radiographically, but important to obtain CT to further localize. In posterior excision, identify axillary nerve in normal tissue first. -HO in elbow (forms in 90% fractured or dislocated elbows in head injured patients). Obtain CT pre-op. Approaches are either posterolateral, medial, or anterolateral.

-REFLEX SYMPATHETIC DYSTROPHY: commonly develops after stroke and TBI.

-characterized by constant severe pain, usually with hypo- and hyperesthesia, along with vasomotor and trophic changes. TREATMENT: physical therapy, amitryptiline, sympathetic blocks. COMMON CLINICAL PATTERNS OF MOTOR DYSFUNCTION (overpowering of muscles on side of deformity) -Adducted/internally rotated shoulder -Flexed elbow -Pronated forearm -Flexed wrist -Clenched fist -Thumb-in-palm -COMPLICATIONS OF SPASTICITY: contractures, hygiene difficulties, decubitus ulcers, fracture malunion, joint subluxation/dislocation, heterotopic ossification, peripheral neuropathy (ulnar nerve at elbow, CTS) TEMPORARY MANAGEMENT OF SPASTICITY DURING NEUROLOGIC RECOVERY: -Focal injections with neurolytic (phenol) or chemodenervating (botulinum toxin A = Botox) agents, which have temporary effects (3-5 months). Determine targets by dynamic EMG. -Splinting -Oral antispastic agents (baclofen, diazepam, clonidine) PHENOL -Derivative of benzene. Denatures the myelin sheath and axon cell membrane, which reduces neural conductivity. Usually 4-7 ml of 5-7% aqueous solution phenol injected to motor endplate region using electrical stimulator/needle. Done percutaneously for pure motor nerves; open if mixed motor/sensory. BOTULINUM TOXIN TYPE A = Botox (brand name) -Protein produced by Clostridium botulinum that inhibits release of acetylcholine. Injected directly into muscle (10-200 U). Total in 1 treatment session 400 U. Wait at least 12 weeks before re-injection. Takes 3-7 days before clinical effect. May use Botox distally and phenol proximal in 1 treatment session. -BASIC TREATMENT GUIDLINES: 1) Operate early, before deformities are severe and fixed. 2) Better underlying motor control means better eventual function. Carefully evaluate the amount of volitional control that each muscle has. 3) Distinguish between the function of the extremity and the function of the patient. 4) Consider the cost of not correcting limb deformity (attendant care, orthotics, skin problems) -MUSCULOSKELETAL ISSUES: 1) HYGIENE, 2) FUNCTION, 3) COSMESIS -GENERAL SURGICAL PRINCIPLES: 1) Lengthen tendons in functional extremities, release tendons in nonfunctional extremities. 2) Fractional lengthening used if need less correction; preserves more strength and more consistent length. Z-lengthen used if need more correction.

-DIAGNOSIS OF SPASTICITY, VOLITIONAL CONTROL: 1) PHYSICAL EXAM, 2) DYNAMIC EMGs: Can help further define spasticity of muscles and volitional activity -FUNCTIONAL VS NONFUNCTIONAL: 1) COGNITIVE (Functional: Able to obey commands, cooperate with and retain rehabilitation, perform ADLs) 2) SENSIBILITY (Functional: Intact pain, < 10 mm 2 point discrimination) 3) MOTOR CONTROL (Volitional control by exam and EMG) SPECIFIC ANATOMIC LOCATIONS: SHOULDER ADHESIVE CAPSULITIS: Symptoms: painful, stiff shoulder. Treatment: NSAIDs, physical therapy, intra-articular injections. Manipulation under anesthesia, arthroscopic release INFERIOR SUBLUXATION: Usually self-limited, but occasionally chronically subluxated and painful (sensory deficit does not match motor deficit). Non-operative treatment: sling. Operative treatment: 1) Biceps sling procedure (Long head of biceps left attached proximally, detached distally, passed proximal to distal through a bony tunnel under biceps groove, looped around and sewn to itself), 2) Coracoacromial (CA) ligament suspension procedure (lateral portion of coracoid with CA ligament detached and fixed to the humeral head with a cancellous screw). SPASTIC ABDUCTION: Caused by supraspinatus. Treatment: supraspinatus slide. Incision over scapular spine. Detach trapezius. Subperiosteally elevate supraspinatus origin from medial scapula. Protect neurovascular pedicle at suprascapular notch. ADDUCTED/INTERNALLY ROTATED SHOULDER: May cause hygiene problems. Offending muscles: latissimus dorsi, teres major, pectoralis major, subscapularis. May need release through deltopectoral approach. ELBOW SPASTIC FLEXION: From brachioradialis, biceps, brachialis. May lead to skin breakdown. For functional extremities: if less than 45 degrees of fixed flexion, then fractional lengthening at myotendinous junction. If greater than 45 degrees of fixed flexion, then biceps tendon Zlengthening. Preoperative EDS, ulnar nerve transposition if ulnar neuropathy. SPASTIC EXTENSION: Uncommon. V-Y triceps-plasty rarely indicated. ULNAR NEUROPATHY: 2.5% incidence with TBI. Possible causes: prolonged elbow flexion, excessive decubitus pressure, heterotopic ossification. Suspect if intrinsic atrophy, confirm by electrodiagnostics. Subcutaneous transposition indicated (not submuscular for HO avoidance) FOREARM SPASTIC PRONATION: Lengthen vs release pronator teres and pronator quadratus depending on function. PT insertion approached in mid-forearm between BR and FCR. PQ approached via palmar midline incision; finger flexors retracted radially. SPASTIC SUPINATION: uncommon. Caused either by biceps or supinator, or both. Z-lengthen vs release of biceps. If still unable to fully pronate, approach supinator from volar Henry approach. Protect PIN (in contact with radius in 25%), release insertion of supinator off radius.

WRIST -Wrist deformity gives patient difficulty with clothing. Also may give CTS. Wrist subluxation in severe cases. SPASTIC FLEXION: From FCR, FCU, PL, FDS, FDP. Attempt to determine what volitional control patients have with these flexors and wrist and finger extensors. Fractional lengthening vs release vs STP tendon transfer vs wrist fusion vs proximal row carpectomy. SPASTIC EXTENSION: Uncommon, from ECRL, ECRB, ECU HAND SPASTIC CLENCHED FIST: FDS more commonly involved than FDP. Evaluate for volitional control (50% have). Evaluate for extensor function (may block median nerve in antecubital space and ulnar nerve in cubital tunnel to help evaluate). Fractional lengthening if functional, STP tendon transfer if nonfunctional. SURGICAL TECHNIQUE: Superficialis-to-profundus (STP) Tendon Transfer: PL transected. FDS tendons sutured together distally and transected. FDP sutured proximally and then transected, fingers extended and FDS and FDP sutured together en masse. Consider ulnar motor neurectomy to prevent intrinsic-plus deformity. May need release intrinisic contracture. SPASTIC THUMB-IN-PALM DEFORMITY -FPL, adductor pollicis, and thenar muscles (flexor pollicis brevis, opponens pollicis, and abductor pollicis brevis). May need fractional lengthening vs z-lengthening of FPL. May need Thenar Slide SURGICAL TECHNIQUE: Thenar Slide: through incision in thenar crease, origins of thenar muscles detached while protecting recurrent branch of median nerve. Adductor Pollicis Release: origin of adductor pollicis released from 3rd metacarpal. 1st dorsal interosseous released from 1st metacarpal. May need to Z-plasty web space skin. INTRINSIC SPASTICITY -May be masked by extrinsic spasticity -Will assume intrinsic plus position, may have swan neck or boutonniere deformity -Perform Intrinsic Tightness Test: If less PIP flexion with extended MP joints, then intrinsics are tight. Test with and without ulnar nerve block at wrist to distinguish between intrinsic contracture vs intrinsic spasticity. -Dynamic EMGs may help with diagnosis TREATMENT: If no contracture and no volitional control, then Neurectomy of Motor Branch of Ulnar Nerve. If contracture, add release of lateral bands on both sides of fingers through dorsal midline incisions. If dynamic or static intrinsic deformity, but with volitional control, then Intrinsic Slide: release origins of interossei off metacarpal shafts, let slide by putting hand in intrinsic minus position

Kay, Terry Light, Michael Tonkin, Virchel Wood, James Dobyns) DEVELOPMENT OF THE HAND -Upper extremity forms from bud to hand in 22 days: days 28-50 of gestation (insult occurs at this time) -3 critical regions: Apical Ectodermal Ridge (PR), Dorsal Ectoderm, Zone of Polarizing Activity (ZPA) ETIOLOGY OF DEFORMITY: Genetic 25%, Environmental 25%, Idiopathic 50% INCIDENCE: 0.2-4.0% CLASSIFICATION (Swanson & Congenital Anomalies Committee of the International Federation of Societies for Surgery of the Hand - IFSSH 1983): -Failure of Formation, Failure of Differentiation, Duplication, Overgrowth, Undergrowth, Congenital Constriction Band Syndrome, Generalized Skeletal Abnormalities

TRANSVERSE DEFICIENCIES (CONGENITAL AMPUTATIONS) -Most commonly at proximal forearm, midcarpal, metacarpal, then humerus -Few indications for surgery. Usually treated with prosthesis. -Surgical options: excision of functionless digital remnants, terminal revision for prosthetic fitting, excision of neuromas, bursae, spurs. -Krukenberg Procedure = forearm bones split to create opposable radius and ulna considered if bilateral below-elbow arrest, especially if impaired vision LONGITUDINAL INTERSEGMENTAL DEFIENCY (PHOCOMELIA) -Finger skeletal structures differentiates this entity from transverse deficiencies -3 types: 1) Attachment of hand to trunk, 2) Forearm with hand attached to trunk, 3) Hand attached to humerus -Associated with thalidomide used in 1950s and 60s -Probably from vascular disruption -Few indications for surgery, mainly treated with prostheses

RADIAL LONGITUDINAL DEFICIENCY (=RADIAL CLUBHAND=RADIAL DYSPLASIA) CLASSIFICATION: TYPE I) Short Distal Radius: Mildly short distal radius, adequate carpal support. Distal radial epiphysis present but delayed. TYPE II) Hypoplastic Radius: Short radius, carpus poorly supported, ulna bowed. Proximal and distal radial epiphyses present, but defective. TYPE III) Partial Absence of Radius: Absence more commonly distal. Carpus is unsupported and ulna bowed (worst in this type). TYPE IV) Absent Radius: Most common type, hand is unsupported and radially displaced.

-Thumb and radial carpal column usually hypoplastic or absent -Ulna is usually short, elbow may be stiff. -Radial fingers may be stiff, have camptodactyly INCIDENCE -1 in 30,000 to 100,000 -Bilateral in 38-50% ETIOLOGY -Insult to apical ectodermal ridge -Environmental factors have been incriminated; occurrence sporadic, except when associated with syndromes (see below) ASSOCIATED SYNDROMES Many, but most common: Fanconi‘s anemia, thrombocytopenia absent radius (TAR) syndrome, Holt-Oram syndrome, and VATER -Fanconi‘s anemia: Autosomal dominant, progressive pancytopenia. Poor long-term prognosis. Mitomycin C test can indicate its presence. Thumb is present. -TAR: Autosomal recessive. Thrombocytopenia in neonate, but improves with age; good longterm prognosis. Delay surgery until blood profile optimal. Radial deficiency is bilateral, Type IV, but thumbs are present. 50% with abnormal knees. -Holt-Oram: Autosomal dominant, also with heart defects. Radial deficiencies are bilateral, and may have triphalangeal thumbs, proximal radioulnar synostosis, proximal humeral defects. -VATER: Vertebral anomalies, anal atresia, tracheo-esophageal fistula, esophageal atresia, renal defects ANATOMIC PATHOLOGY -Radial sided muscles (flexors and extensors) are abnormal or absent. Radial nerve usually ends at elbow. Radial artery usually absent. TREATMENT NON-OPERATIVE -All start with stretching and splinting/serial casting OPERATIVE INDICATIONS FOR SURGERY -Function Improvement by improving wrist stability, extrinsic tendon excursion. Reconstruct or pollicize thumb if needed. -Cosmesis CONTRAINDICATIONS TO SURGERY -Life-threatening conditions, older population who functions adequately, bilateral with elbow stiffness where deformity allows hand to reach mouth (then correct only 1 limb), most Type I and some milder Type II do not require surgery. OPERATIVE TECHNIQUE

-Wait until after 6 months of age -3 main options for incisions: 1) dorsal S-shaped with convexity ulnar and excision of redundant ulnar skin in V-shape, 2) Z-plasty on radial side with longitudinal ulnar incision incorporated into ellipsoid skin excision, 3) bilobed rotational flap of Evans: rotates excess ulnar skin to radial side. -Perform in 1 stage if hand can be reduced onto end of ulna -After skin incision, exercise caution in dissecting since NV structures are very superficial and radial. Detach the extensor retinaculum radially and dissect out tendons, identify ECU. The BR, ECRL & B, FCR may be fibrotic and fused; release them and tag ones that will be useful for transfer. Excise fibrous radial anlage. Mobilize the carpus dorsally and palmarly by incising the capsule transversely. Mobilize the distal ulna, but maintain a soft tissue cuff to preserve vascularity to the distal ulnar physis. Transfer carpus to ulnar side of ulna; if this is not difficult and there are adequate radial muscles to transfer to ECU, then radialize (=transfer carpus to ulnar side of ulna without carpal resection), hold with 1-2 K-wires from 2nd metacarpal (or 3rd if pollicizing index finger) to ulna. If hand cannot easily be reduced onto end of ulna, then centralize (partial carpal resection and transfer/fuse ulna into radial side of carpus). Requires removing cartilage off of ulnar head. Other option: shortening ulnar osteotomy. Transfer radial muscles to ECU. Post-op: LAC x 4 weeks, then splint. Intermittent splinting may be needed until skeletal maturity. -If hand cannot be reduced onto end of ulna pre-operatively, consider 2 stage procedure. 1st stage: Soft Tissue Distraction with External Fixator: (i.e. Kessler device) placed with parallel wires in metacarpals and ulna. This may require formal release: radial skin Z-plasty, distal release and tagging of BR, ECRL & B, FCR. Excise fibrotic tissue. Wait 1 week, then distract 0.5-1 mm/day for 4-weeks, then hold 1 week before 2nd stage (see above). -Ulnar osteotomy may need to be performed (at midshaft) if severely bowed. Otherwise, consider delaying osteotomy (decrease risk to blood supply of ulnar physis) COMPLICATIONS -Recurrence and premature distal ulnar physeal closure

ULNAR LONGITUDINAL DEFICIENCY (=ULNAR DYSPLASIA=ULNAR CLUBHAND) -Ulnar digits usually absent; radial digit anomalies in 50%. -May have carpal, humeral, and shoulder hypoplasia. CLASSIFICATION: -TYPE 1: Hypoplasia of the Ulna: Minimally short ulna -TYPE 2: Partial Aplasia of the Ulna: Distal ulna absent -TYPE 3: Total Absence of the Ulna: Posterolateral dislocation of radius at elbow -TYPE 4: Radiohumeral Synostosis: Ulna usually absent INCIDENCE: -1 in 100,000 -Radial to ulnar clubhand 4.5:1

-Males > female 3:2 -Bilateral 25% ETIOLOGY: -Most cases sporadic and non-genetic; may be associated with syndromes ASSOCIATED ANOMALIES -50% with anomalies in other limbs. Chest/abdomen anomalies uncommon (vs. radial deficiency) -Ulnar Mammary Syndrome: AD, mammary gland hypoplasia, genital anomalies, abnormal dentition PATHOANATOMY: -Ulnar NV bundle in subcutaneous tissue with anlage -Ulnar and median nerves present, ulnar artery may be absent -FCU absent, as may be PL and FDP V -Wrist usually stable. Functional problems usually from hand anomalies. TREATMENT -Splint/stretch initially. 2 stages: 1) Position wrist, 2) Elbow 90 degrees, forearm neutral -Hand Reconstruction: 90% of surgery in Ulnar Dysplasia -Anlage Excision if not possible to correct wrist deformity to within 30 degrees or if increasing deformity. TECHNIQUE: Lazy S vs. Z-plasty skin incision over ulnar wrist. Protect NV bundle (superficial and close to anlage). Resect anlage to at least 1/3 forearm length. Hand should reduce easily. If severe radial bowing, osteotomize and fix with K-wires in young, plate in older patient. High LAC x 4 weeks. -Radial Head Excision if functional problems with ROM (rotation, F/E) -One Bone Forearm if radial head excised and elbow unstable -Osteotomy of the Radiohumeral Fusion Mass to place hand in functional position if needed.

HYPOPLASTIC AND ABSENT DIGITS -SYMBRACHYDACTYLY: together, short fingers. Wide range of presentation: short finger, cleft hand like, monodactylous, peromelic (all digits and metacarpals absent). Nail remnants present (primary disturbance is bone formation). Not hereditary. Unilateral. -Treatment options: division of syndactyly, deepening of the 1st web (=phalangization), digital reconstruction, free phalangeal transfer, digital lengthening, toe to hand transfers, prosthesis BRACHYMETACARPIA (SHORT METACARPALS) -Occurs in many syndromes & diseases (46+), i.e. pseudohypoparathyroidism (hypocalcemic but unresponsive to parathyroid hormone) & pseudopseudohypoparathyroidism (normocalcemic, both with short stature, M.R., round face), Turner‘s (XO), cretinism, JRA; generally sign of greater disorder -Usually ring and small fingers -Treatment usually unnecessary, unless significant grip strength loss or deformity

-Surgical options: 1) OSTEOTOMY / BONE GRAFT (release deep transverse metacarpal ligament and interossei, chevron or transverse osteotomy, ICBG, K-wire). 2) DISTRACTION LENGTHENING / EX-FIX ABSENT EXTENSOR TENDONS TO THE FINGERS (EXCLUDING THE THUMB) -Rare condition. AD inheritance. No associated anomalies -Isolated Finger Type: IP‘s cannot extend. Central slip &/or lateral bands absent -Multiple Finger Type: MP‘s cannot extend. EDCs hypoplastic TREATMENT -Initially splint to minimize contractures -Palmar release at 1-2 years: FDS released or lengthened at wrist, skin released +/- FTSG, volar plate +/- collaterals released -Tendon transfers at 5 years: -For loss PIP extension: 1) FDS TRANSFER TO EXTENSOR MECHANISM (Kelikian), or 2) TRANSFER LATERAL BAND FROM ADJACENT FINGER (Snow) -For multiple digits: 1) ECRL TRANSFER, or 2) FDS TRANSFER CLEFT HAND -True Cleft Hand (hereditary - AD, 1-4 limbs, no finger nubbins) vs. Atypical Cleft Hand (=Symbrachydactyly; not hereditary, 1 limb-no feet, finger nubbins with nail remnants) -No forearm, elbow anomalies INHERITANCE: Variable manifestation of genetic processes; commonly AD and associated with syndromes, the most common: EEC (Ectrodactyly – absence of fingers, Ectodermal dysplasia – skin & hair fair and thin, Cleft lip/palate) CLINICAL FEATURES -Unilateral or bilateral, may involve feet -Syndactyly in digits bordering cleft common -In cleft, metacarpals +/- present, and may be transverse. -PIP flexion contractures CLASSIFICATION BASED ON 1ST WEB SPACE (Manske) -Type I: normal web, Type IIa: mildly narrowed web, Type IIb: severely narrowed web, Type III: syndactylized web, Type IV: merged web (to cleft), Type V: Absent web SURGICAL TREATMENT ISSUES -Progressive deformity (syndactyly, transverse bones) -1st web space -The cleft -Management of the absent thumb -The feet SURGICAL OPTIONS:

REMOVAL OF TRANSVERSE BONES (metacarpal or proximal phalanx): transverse bone widens cleft with growth SYNDACTYLY RELEASE 1ST WEB SPACE RELEASE SNOW-LITTLER PROCEDURE: Transfer 2nd ray to base of 3rd metacarpal (or closing wedge carpal osteotomy if 3rd metacarpal absent) and deepen 1st web space by rotational flap from cleft. OTHER PROCEDURES: -Deep transverse metacarpal ligament reconstructed with proximal ½ of A2 pulley from each digit (Saito, Ogino) -May need rotational osteotomy of thumb/thumb reconstruction. -May need toe transfer. THE FEET -Fibular ray is last remaining digit, tibial ray is penultimate. Fibular ray is usually the more important weight-bearer. -Surgery rarely required, usually only if ray is deviated or duplicated, making shoewear difficult. Osteotomy or resection may be required. SYNDACTYLY EMBRYLOLOGY – Separation of fingers normally occurs at the completion of embryogenesis by apoptosis = programmed cell death. Syndactyly occurs if the process fails or stops short of completion INHERITANCE AND ASSOCIATED CONDITIONS – Occurs either isolated or as part of other syndromes (63+ known). 1 in 2000 birth prevalence. Often inherited. Most commonly between long and ring fingers. NOMENCLATURE -Simple (pure) syndactyly = if only skin or nail components involved -Complex (complicated) syndactyly = bony involvement -Complete = connection involves entire finger -Incomplete = partial connection EXAMINATION -Absence of differential motion between fingers or synonychia (confluence of nails) indicates probably complex syndactyly. OPERATIVE TREATMENT Goal: improve function and appearance Contraindications: Lack of individual stable skeletal elements for each digit, vascular or soft tissue insufficiency, patient too ill for surgery TECHNIQUE -Wait until at least 1 year of age, unless adjacent digit deformation -Adjacent digits must be done at separate times so that both digital vessels are not operated on

-Match Z incisions from dorsum to palm -Many web space flaps. Web space has 35-45 degree slope. Flap length must be longer than ½ proximal phalanx length. 1 technique: Offset triangles dorsally and palmarly -Full thickness skin graft (from groin) defects AMNION DISRUPTION SEQUENCE (=CONSTRICTION RING SYNDROME =STREETER’S DYSPLASIA) CLINICAL PICTURE: Defect in the amnion (the innermost layer of the placenta) with strands becoming detached and wrapping around limbs or digits resulting in constriction rings and distal edema, neurologic impairment, fusion (syndactyly), amputations. -Epithelial inclusion cysts or recurrent infection due to retained epithelial elements ASSOCIATED CONDITIONS: Oligohydramnios and prematurity with fluid leak, but usually normal pregnancy ASSOCIATED ANOMALIES: Neurogenic, dysvascular clubfeet with calf bands; Facial clefts OPERATIVE TREATMENT -Distal edema with impending tissue loss is indication for urgent excision of band (1/2 of circumferential band) and Z-plasties. Moderate cases can be improved with excision, Z-plasty as well. May need numerous secondary reconstructions. Minor cases need no treatment. POLYDACTYLY = more than 5 fingers -Most common congenital hand abnormality -Additional digit often small and dysplastic -Residual ―normal‖ digit smaller than normal --3 types: I) extra soft tissue only, II) includes bone, tendon, cartilage, III) completely developed with own metacarpal (rare) THUMB POLYDACTYLY CLASSIFICATION WASSEL CLASSIFICATION SYSTEM -7 types: Type I) Y-shaped distal phalanx, Type II) two separate distal phalanges, Type III) Yshaped proximal phalanx, Type IV) two separate proximal phalanges, Type V) Y-shaped metacarpal, Type VI) two separate metacarpals, Type VII) triphalangeal component (see below) -Wassel Type IV is most common BUCK-GRAMCKO UNIVERSAL CLASSIFICATION SYSTEM -―Type I‖ refers to digit, level: DIST, IP, PROX, etc., add ―+‖ for each triphalangeal component. Example: Type I IP = Wassel II. TREATMENT -Goal of surgical treatment: single, mobile, stable thumb -Surgical strategy: Usually excise radial thumb and retain ulnar thumb, since radial one is usually less developed. SURGICAL TECHNIQUE -Converging zigzag incisions -Distal bifurcations usually have 2 neurovascular bundles; retain them both. Proximal bifurcations may have 3-4 bundles; sacrifice bundles that lead to excised skin.

-Extrinsic tendons (FPL & EPL) are usually eccentrically inserted, which can lead to postoperative deformity. 3 options: 1) Partial division of tendon to balance, 2) Detach and centrally re-attach the tendon, 3) Shift tendon from deleted digit to the retained digit in a balancing manner. -For Wassel Types IV-VI, the APB inserts on the proximal phalanx of the radial thumb. Elevate the APB and transfer it to the retained ulnar thumb. -For Wassel Type II & IV, retain the radial collateral ligament. Detach the insertion with periosteum/capsule and re-attach to the retained ulnar digit. -For Wassel Type II & IV, the proximal bone is too wide; narrow it by a longitudinal osteotomy. Pin the joint in a reduced position, and suture the capsule, periosteum, and the collateral ligament. -If there is bony deformity leading to angulation, perform closing or opening wedge osteotomy. -If web space is narrowed (Wassel IV-VI), then widen it by Z-plasty or local flaps (see ch.66) -Post-op, leave K-wire 6 weeks COMPLICATIONS -Angular deformity or joint stiffness. May require revision or arthrodesis. MODIFIED POLLICIZATION SEGMENTAL TRANSPOSITION -In some Wassel VI thumbs, the radial digit possesses a better CMC joint. In this case, transpose the distal portion of the ulnar digit to the proximal portion of the radial digit, the so-called: ―ontop-plasty‖ -The common digital nerve to the index finger and ulnar thumb is teased apart distal to proximal and the radial digital artery to the index finger is ligated. -Osteotomize the metacarpal of each thumb through the diaphyses and excise the distal radial thumb and proximal ulnar thumb‘s metacarpal. -Retain and mobilize the extrinsic and intrinsic tendons to the ulnar thumb. Transfer the APB (see above). -Rotate the transferred digit 120 degrees pronated and fix with K-wires. BILHAUT-CLOQUET TECHNIQUE=combining 2 small duplicate thumbs by central resection of soft tissue and bone. -Most appropriate for Wassel Type II or I thumbs -Problems: 1) 2 thumbs are rarely mirror images, 2) Growth arrest may occur, 3) Joint may be incongruous, leading to OA. THUMB POLYDACTYLY WITH A TRIPHALANGEAL COMPONENT CLASSIFICATION -These are Wassel Type VII. Wood‘s modified classification: Type VIIA) Radial triphalangeal thumb bordered by hypoplastic ulnar thumb, Type VIIB) 2 complete triphalangeal thumbs, Type VIIC) Ulnar triphalangeal thumb bordered by hypoplastic radial thumb (most common), Type VIID) 3 thumbs with central triphalangeal thumb bordered on both sides by hypoplastic thumbs TREATMENT -If single triphalangeal thumb with 1 or 2 hypoplastic digits, then excise hypoplastic ones and reconstruct triphalangeal thumb -If 2 triphalangeal thumbs, then excise radial one and reconstruct ulnar one -If complete biphalangeal thumb with a triphalangeal thumb, then excise triphalangeal thumb

-If CMC issues, consider ―on-top-plasty‖ TRIPHALANGEAL THUMB =Interposition of an extra phalanx between 2 normal phalanges of the thumb. -Males=females -Bilateral 87% -2 variations: 1) wedge shaped extra phalanx with minor increase in thumb length (more often unilateral), 2) fully developed phalanx with the hand appearing like a 5 finger hand (may actually be a duplicated index finger) (50% of cases) ASSOCIATED ANOMALIES: thumb and hallux polydactyly, cleft feet, Holt-Oram, Fanconi‘s pancytopenia, etc. TREATMENT -Z-plasty for mild web contracture, dorsal flap rotation if severe -Removal of delta phalanx if < 1 year old. Fuse to other phalanx in older patient. -For 5 fingered hand, pollicization (see ch. 66) -For thenar muscle deficiency, opponensplasty with ring FDS (see ch. 48) or Huber procedure CENTRAL POLYDACTYLY = affecting ring > middle > index fingers. -Often occurs with syndactyly (=synpolydactyly) -Frequently bilateral, often AD -Feet also frequently involved CLASSIFICATION (Stelling) -Type I: soft tissue mass not adherent to bone, Type II: duplicated digit with normal bone articulating with enlarged metacarpal or phalanx (IIA not syndactylized, IIB syndactylized), Type III: complete duplication of ray TREATMENT -Ablation LITTLE FINGER POLYDACTYLY -Hereditary, common in African-American population (10x more common in African-American children than Caucasian) -Most common hand malformation -Often bilateral -Many rudimentary and ligated in nursery; not seen by hand surgeon CLASSIFICATION (Stelling) -Type A: well formed digit with bony articulation -Type B: small, poorly formed digit with narrow soft-tissue pedicle ASSOCIATED ABNORMALITIES -African-American children frequently have isolated Type B, whereas Caucasian children may have associations

TREATMENT -Type B may be ligated in nursery (but may be left with nipple-like residual), or surgery: excise with elliptical incision (avoids nipple-like residual), sharply divide digital nerves, cauterize/ligate digital nerves -Type A needs surgical ablation and reconstruction (similar principles as in thumb polydactyly). Collateral ligaments and ADM and FDM attach onto ulnar (ablated) digit; need to reconstruct to retained digit. ULNAR DIMELIA (=mirror hand) -Characterized by 2 ulnae, no radius, 7-8 fingers, and no thumb -Extremely rare TREATMENT -Pollicization / ablation reconstructive surgery SYMPHALANGISM (stiffness of IP joints) -failure of differentiation -stiffness varies. Classic: little motion -near normal length digits -absence palmar creases INHERITANCE -50% hereditary, have other anomalies ASSOCIATED ANOMALIES – brachydactyly, carpal coalitions, hand defects ANATOMIC PATHOLOGY – abnormal joints, soft tissue, possible ankylosis SURGICAL INDICATIONS – Rare. Options: silicone arthroplasty when mature, fusion, chondrodesis ARTHROGRYPOSIS Full name = ARTHROGRYPOSIS MULTIPLEX CONGENITA (arthro = joint, gryp = curved, multiplex = multiple, congenital = present at birth) =multiple contractures in multiple body areas that are present at birth, contractures are nonprogressive and often improve dramatically over time with prompt physiotherapy and orthopaedic care -associated with many different specific conditions and syndromes -exact pathogenesis is unknown, but all involve fetal akinesia (decreased fetal movement), from multiple processes: muscle abnormalities, nerve abnormalities, restricted intrauterine space, vascular insufficiency, maternal illness. -occur in 1:3,000 live births -3 main groups: Group 1 – mainly limb involvement, Group 2 – limbs and other body parts, Group 3 – limb and central nervous system Group 1 – Amyoplasia (―classic arthrogryposis‖) is the most common type (1/3 of all cases), mainly with limb involvement, amyoplasia (a = no, myo = muscle, plasia = growth), muscles are hypoplastic and replaced by fibrous tissue. Usually symmetrical with typical positioning of shoulders internally rotated and adducted, elbows extended, forearm pronated, and wrist and fingers flexed. Normal intelligence. Trunk is spared. Feet have severe talipes equino varus

deformity. Waxy skin devoid of skin creases, limbs show muscle wasting and a paucity of subcutaneous tissue. TREATMENT GOALS: -Independent function for self-feeding and perineal care -Early treatment: passive motion stretching, serial casting, splinting SURGICAL OPTIONS -Timing of surgery is controversial (usually recommended before school age: 4-5 years) -SHOULDER: Derotation humeral osteotomy, in slight internal rotation to allow for hand-tomouth use and midline activity (do not perform muscle releases since arthrogrypotic patients frequently use humeral-thoracic pinch to hold objects) -ELBOW: is often the most challenging joint, since limited flexion inhibits hand-to-mouth activity. Need to take into consideration that 1 elbow needs to be able to extend for perineal care. Also, patient may need elbow extension for ambulation, either for crutches or by pushing off of the floor. -1st goal for the elbow: passive motion. If fails non-operative measures, then consider triceps lengthening and posterior capsular release. SURGICAL TECHNIQUE: Posterior incision, release ulnar nerve and transpose anteriorly subcutaneously, ―V-Y‖ triceps lengthening, Divide posterior capsule from medial to lateral, splint past 90 degrees x 3 weeks, then start A, AA, PROM. -2nd goal for the elbow: active motion. Options: Tendon transfers to biceps (triceps to biceps, latissimus to biceps, pectoralis major, flexor-pronator mass) Unfortunately, results are inconsistent due to poor passive motion and lack of good donor muscles. (VanHeest, Waters, Simmons. Surgical treatment of arthrogryposis of the elbow. J Hand Surg 1998;23A:1063-1070: 18 tendon transfers for 14 patients, average f/u 4 years. 9 triceps (7 good, 1 fair, 1 poor), 4 latissimus (2 good, 2 fair), 5 pectoralis (1 good, 3 fair, 1 poor)) -FOREARM AND WRIST: Forearm pronation and wrist flexion and ulnar deviation are typical contractures. Proximal row carpectomy for mild to moderate contractures, Dorsal wedge osteotomy of the mid-carpus for severe contractures. SURGICAL TECHNIQUE: Volar (longitudinal) and dorsal (transverse) approaches. Volarly, tight forearm fascia is incised, wrist flexors are inspected. Normal flexors are considered for transfer dorsally to aid in wrist extension; abnormal flexors or incised or lengthened. Dorsally, transverse incision made for later excision of redundant skin and dermadesis. ECU released for later transfer to the radial wrist extensors (ECRB & L). Finger extensor mobilized and protected. Distally based capsulotomy flap (―U‖ shaped flap) raised to expose the carpus. Biplanar wedge osteotomy made (use preliminary K-wires and mini-fluoro to guide cuts) with proximal cut perpendicular to the forearm long axis and distal cut perpendicular to the metacarpals (wedge is wider at the dorsal and radial margins; avoid violation of the palmar capsule). Cut the wedge with a scalpel, osteotome, or saw, depending on age of child. Interosseous sutures and/or K-wires used to fix the bone. Close capsule and mobilize ECU 5 cm proximal to wrist and transfer subcutaneously to radial wrist extensors (use wrist flexor if ECU not present). LAC x 6 weeks. -THUMB AND FINGERS: -Thumb – contracted, clasped: common finding. May be released to enhance prehension and function.

-Fingers are stiff, fixed in flexion and ulnarly deviated. Unfortunately, surgical treatment is unsuccessful. Osteotomy may be used for poorly aligned fingers. Pterigium = skin and soft tissue webbing between contracted joints, literally means ―wing‖

THE WINDBLOWN HAND SYNOSTOSIS -Caused by failure in physiologic cell death and segmentation. Leads to failure of differentiation of parts.


FOREARM SYNOSTOSIS -Position is usually pronation -Bilateral in more than 60% -Usually FROM (or near) of elbow -Usually no pain -4 Types (Cleary & Omer): 1) Fibrous Synostosis, 2) Bony Synostosis, 3) Associated with Posterior Dislocation of Radius, 4) Associated with Anterior Dislocation of Radius -1/3 with associated abnormalities (Apert‘s, Arthrogryposis, Holt-Oram, etc.) -20% with familial pattern TREATMENT -Indications for operative treatment controversial; related to degree of deformity/loss of function and bilaterality. OPERATIVE TECHNIQUE – DEROTATION OSTEOTOMY THROUGH FUSION MASS -Posterior incision along subQ ulnar border. Osteotomize mid-aspect of synostosis. Rotate distal forearm to desired position, then place K-wire longitudinally from olecranon across osteotomy; 2nd wire placed obliquely. LAC with elbow 90 degrees until union (usually 8 weeks). -Significant complications in 36%: Loss of position, non-union, circulatory compromise, PIN palsy. CARPAL SYNOSTOSIS (=COALITION) -Incidence much more common in black population, especially from West Africa (9.5%) versus white population (0.2%) -Often bilateral and may be familial -LTq coalition most common, followed by CH -Several associated syndromes -CLASSIFICATION OF LTQ COALITION (Minaar): Type I) Proximal Pseudarthrosis, Type II) Proximal Osseous Bridge with Distal Notch, Type III) Complete Fusion, Type IV) Fusion with Associated Carpal Anomalies -Usually asymptomatic resulting in no wrist dysfunction; requires no treatment

METACARPAL SYNOSTOSIS HYPERPHALANGISM = extra phalanx between phalanges of a finger, excluding the thumb CAMPTODACTYLY means ―bent digit‖. Congenital flexion deformity of PIP, usually little finger; can affect other fingers -Incidence: true not known, prob. 1% -Mix of inherited and sporadic -2/3 bilateral -Most present in infancy -Males = Females -Usually progressive deformity ASSOCIATED SYNDROMES – Many: Oro-facio-digital, Oculo-dento-digital, Zellweger‘s, Aarskog‘s PATHOANATOMY: Muscular abnormalities (lumbrical and FDS most common) are primary defect, but all structures can be involved CLINICAL FEATURES AND DIAGNOSIS -Abnormal flexed posture of PIP -Reducible vs. irreducible -Rotational deformity -Lateral x-ray may show bony changes TREATMENT: Start with stretching / splinting (static and dynamic) works in majority of cases. Continue through adolescence. Surgery contraindicated if < 30 degrees. Surgery usually disappointing: FROM usually not achieved. Surgical procedures: 1) Identify cause on volar surface, 2) Rebalance PIP by flexor to extensor transfer, 3) Release tight volar structures TREATMENT ALGORITHM -Actively reducible: Splint. Lasso procedure if fails. -Passively reducible: Splint. Tendon transfer and release lumbrical if fails -Irreducible, <30 degrees: Night splint, no surgery -Irreducible, >30 degrees, fixed block: Release -Irreducible, >30 degrees, rubbery block: Splint. Release if fail to maintain <30 degrees SURGICAL TECHNIQUE: Zig incision from A1 to PIP. Lumbrical and Superficialis explored and released if needed. Release as needed: skin, SQ, flexor sheath, access collateral ligaments proximal attachment to volar plate. FTSG usually needed. Splinting must continue after. CLINODACTYLY (means ―curved digit‖) = excessive (more than 10 degrees; up to 10 degrees is normal) radial or ulnar angulation of a digit due to an abnormally shaped short phalanx (may also have flexion deformity)

-Small finger clinodactyly is common, inherited, usually bilateral (most common site is small finger middle phalanx) ANATOMIC PATHOLOGY -May be from a trapezoid shaped phalanx or a ―delta phalanx‖= triangular bone phalanx with a physeal plate the is C-shaped or ―bracketed‖ around 1 side (may also occur in metacarpals and metatarsals) ASSOCIATED ANOMALIES -Ulnar dysplasia, brachydactyly, symbrachydactyly, craniofacial syndromes (Carpenter‘s in particular), syn and synpolydactyly. Thumb delta phalanx in Apert‘s, diastrophic dwarfism, triphalangeal thumb, Rubinstein-Taybi. TREATMENT -Rarely causes functional problems; treatment for cosmetic reasons APM: If true delta phalanx that will predictably result in short and/or excessively angulated digit, bracket resection and fat interposition at 3-4 years old. If trapezoidal phalanx, wait until near skeletal maturity and perform closing wedge osteotomy. KIRNER’S DEFORMITY = progressive palmar and radial curvature of the distal segment of the little finger ETIOLOGY: Idiopathic, nontraumatic disruption of distal phalanx physis -Female:male 2:1 -Common to be bilateral -Cosmetic INHERITANCE: Sporadic or AD TREATMENT: Rarely indicated: 1) Cosmetic deformity; 2) Functional loss (i.e. musical instrument) SURGICAL OPTIONS: DORSAL HEMIEPIPHYSIODESIS OPENING WEDGE OSTEOTOMIES: with K-wires, +/- bone graft

RADIAL HEAD DISLOCATION -may be congenital, developmental, or traumatic MADELUNG’S DEFORMITY = palmar, ulnar deformity of distal radius CLINICAL PICTURE -Usually female adolescent, frequently bilateral -Present with deformity, pain, limitation of ROM (especially supination) -Tendon irritation, locking, or rupture may occur -Median nerve compression may occur INHERITANCE -Most cases sporadic; true isolated Madelung‘s deformity believed to have a hereditary component, but this is not clearly defined -Occurs as part of Leri-Weill syndrome, a dyschondrosteosis with mesomelic dwarfism (autosomal dominant)

DIFFERENTIAL DIAGNOSIS -Partial growth arrest after trauma or infection ASSOCIATED ANOMALIES -Mucopolysaccharidoses, achondroplasia, multiple hereditary osteochondromata, multiple epiphyseal dysplasia, multiple enchondromatosis (Ollier‘s disease) PATHOLOGIC ANATOMY -Disruption of normal growth of the palmar, ulnar portion of the distal radial physis -Abnormal volar wrist ligaments tether the carpus and produce asymmetric loads on the physis -Abnormalities of the pronator quadratus produce deforming loads RADIOGRAPHIC FINDINGS -RADIUS: inclination of radial articular surface, dorsal ulnar curve, diminished length, triangular shaped epiphysis -CARPUS: wedge-shaped carpus, ulnar palmar translocation -ULNA: broad, dorsally prominent. Diminished growth. -Assess severity by: 1) longitudinal alignment of forearm with 3rd metacarpal, 2) radial inclination, 3) percentage lunate contact with radius OPERATIVE TREATMENT -If found early with continued growth potential, physiolysis (=palmar approach, release short radiolunate and radiotriquetral ligaments, removal of abnormal physis to expose normal remaining plate and fat interposition) -If after skeletal maturity, then release short radiolunate and radiotriquetral ligaments, ―dome‖ osteotomy of distal radial metaphysis. May need proximal radial osteotomy if significant proximal radial bowing. Shorten ulna if long or impaction present. -Prophylactically check siblings MACRODACTYLY, literally “large digit” -Cause unknown. Abnormal nerve supply is prevailing theory. ANATOMIC PATHOLOGY: -All structures are enlarged. Fibrofatty enlargement of nerves & subcutaneous tissue. Enlarged bones longitudinally and transversely, possibly with deposits and ankylosis. Thickened skin, flexor tendon sheath, & arterial muscular walls. -One of most rare congenital anomalies 0.9% -Not usually inherited -2 forms: static and progressive -Unilateral in 95% -Males slightly > Females -Digit incidence: IF>MF>Thumb>RF>SM. Multiple digits 2-3x > Single digit. IF/MF, IF/thumb most common combinations.

-Sensibility usually normal -Digits angulate and stiffen with age -Associated with CTS, digit triggering ASSOCIATED ANOMALIES -Not usually associated with systemic defects -Syndactyly in 10% -Found in Klippel-Trenaunay-Weber syndrome (vascular anomalies: portwine cutaneous hemangiomas, varicose veins, hemihypertrophy) -Found in von Recklinghausen‘s disease (cafe-au-lait spots, cuntaneous neurofibromas) -Found in PROTEUS SYNDROME (Macrodactyly of hands & feet, hemihypertrophy, pigmented nevi, subcutaneous tumors. Named from Proteus, the Greek god, prophetic old man of the sea, could change shape to avoid capture. So named because of its many variable and changing phenotypes. Original Elephant Man probably had this, and not neurofibromatosis) RX: -Amputation vs. surgical debulking -2 stage SURGICAL DEBULKING, at least 3 months apart, doing ½ of finger at a time, convex side first. TECHNIQUE: Midlateral incision, find and protect NV bundle, debulk fibrofatty tissue from midpalmar to middorsal. Strip branches of digital nerves, preserve digital arteries. In younger child, espiphysiodesis at a time when the affected finger has reached the same length as the corresponding finger of same-sex parent. May need closing wedge osteotomies; can perform through physes—this also shortens. Fillet out distal ½ of distal phalanx to further shorten. In older child/adult, narrow phalanges ¼ width with burr. Resect excess skin. May need CTR, go proximal to normal median nerve. Drain post-op. -If only 1 finger is involved, ray amputation is an option as well, especially if inhibits function, stiff, anesthetic. -Never amputate enlarged thumbs; instead debulk and fuse MP joint. CONGENITAL PSEUDARTHROSIS OF THE FOREARM -Rare -Also seen in tibia, femur, clavicle, humerus, 1st rib -Either 1 or both bones -Differentiate it from non-union by radiolucent lesion in bone, little callus, tapered bone end ASSOCIATED ABNORMALITIES -Neurofibromatosis ANATOMIC PATHOLOGY -Postulated to be related to vascular or nerve abnormality BOYD CLASSIFICATION -Type I: Cystic lesion in bone, fracture through site fails to heal. Acts more like fibrous dysplasia -Type II: Tapering of bone; microscopically similar to hamartomatous tissue seen in neurofibromatosis TREATMENT -Indicated to stabilized ulna and prevent shortening, to restore hand function

-Best options: free vascularized bone graft (APM: from fibula; with fusion of distal fibular to tivia to avoid valgus ankle deformity), formation of 1 bone forearm, electrical stimulation, osteotomy, Ilizarov.

CHAPTER 16 – STIFF JOINTS (H.K. Watson, J. Weinzweig) PATHOPHYSIOLOGY -Predisposing factors to joint stiffness: Injury, infection , excessive immobilization, inadequate splinting -Negative hand (=Intrinsic minus hand) results (IP flexion, MCP extension, thumb adduction, wrist flexion). WHY? MCP is key. Edema, intraarticular fluid collection in MCP. At near full extension, the MCP has max capsule and collateral laxity and intracapsular fluid capacity. Therefore, this hydraulically drives the MCP joints into extension. This position increase flexor tension and decreases extension tension, so the IPs flex. PHYSICAL EXAM: BOUTONNIERE TEST: DIP may be flexed when PIP flexed. Passively extended PIP brings DIP into full extension. BUNNELL TEST: Tests for intrinsic tightness. In patient with intrinsic tightness, PIP and DIP unable to be flexed when MCP extended. If MCP passively flexed, then PIP and DIP easily flexed. VOLAR PLATE TEST: Significant pain with passive flexion of PIP (may have extension contracture). Most common cause is volar plate avulsion (from hyperextension) with or without small bone fragment avulsed from middle phalanx base. If positive 6-9 months after injury, may need volar plate repair of middle phalanx. VOLAR PLATE ANATOMY: -Significant difference in MCP and IP volar plates. MCP volar plate is collapsible (30-100%) and IP volar plate is relatively not collapsible (1mm-10% length change). IP volar plate slides proximally in flexion. IP JOINT CONTRACTURE: -In IP contracture, adhesion and fibrosis occurs proximal to volar plate in the form of pathologic structures called CHECK REINS= 2 collagenous bands from the proximal volar plate to the ASSEMBLY LINES (=2 ridges on the volar lateral proximal phalanx to which are attached the flexor tendon sheath, Cleland‘s and Grayson‘s ligaments, oblique retinacular ligaments of Landsmeer, the transverse lamina of Landsmeer, and the transverse metacarpal ligament/volar plate proximally.). Communicating artery of vincula passes beneath check-reins 3mm proximal to volar plate. -Although some fibrosis of capsule and collateral ligaments occurs, the main structures preventing IP extension are check-reins. DIP JOINT CONTRACTURE: -Seldom a problem

-If associated with swan-neck or boutonniere, then treat underlying problem -If with fixed extension deformity, consider dividing most dorsal and lateral fibers of extensor tendon. Occasionally, complete extensor tendon transection indicated with severe burn contracture or untreatable boutonniere deformity. -Late untreated mallet deformity: arthrodesis is frequently treatment of choice. Seldom adequately salvaged by tendon reconstruction. PIP JOINT CONTRACTURE: -Divided into congenital, in utero, and acquired CONGENITAL CONTRACTURES: -Usually secondary to incomplete development of joint, is abnormal radiographically. Usually fixed in full extension. -RX: Surgical release at 6 months (conservative RX – splinting- does not work)

-SURGICAL TECHNIQUE: PIP joint opened through ulnar and radial mid-lateral incisions. Longitudinal incisions made in capsule just volar and dorsal to collaterals. May need to excise both collaterals. Cartilage reshaped with #11 or Beaver blade. May need to remove dorsal capsule, but leave extensor tendon. Bulky dressing post op, PROM at 3-5 days, then serial splinting for at least 1 year. Motion usually not full; 60 degrees flexion considered excellent result. IN UTERO CONTRACTURES: See Chapter 15 ACQUIRED CONTRACTURES -Most common, usually from trauma or post-op FLEXION CONTRACTURES: -Non-operative RX: Splinting: JOINT JACK: 1 hour before bed, tighten Q2-3 min as tolerated, loosen ½ turn. If pain prevents sleep, use 2 x 1 hour-sessions during day; may need for 6-12 months. WIRE-FOAM SPRING EXTENSION SPLINT: May be more acceptable for daytime use (less bulky). Other RX: Serial casting. -Operative RX: If sudden stop of extension or fail/cannot tolerate splinting. Options: Check-Rein Ligament Release (Watson) ( Results: Full extension of PIP in 96% (Watson JHS 1979), or PIP Collateral Ligament Excision (Eaton) – (see Surgical Techniques for both) EXTENSION CONTRACTURES: -Most common cause: extensor hood adhesions. Bone deformity another cause. -Non-operative RX: ROM, JOINT STRAP: Placed over middle phalanx and tightened Q2-3 minuts as tolerated, 2 x 1 hour-sessions during day; may need for 6-12 months. -Operative RX: DORSAL CAPSULOTOMY: Dorsolateral approach, transverse lamina of Landsmeer divided and lateral band elevated, preserve central slip. Incise dorsal capsule and flex. Release adhesion between extensor hood and phalanges. If ―jumps‖, release dorsal fibers of collaterals. If severe, may need to incise entire capsule, divide collaterals, and free volar plate

adhesions. Make palm or distal forearm incision, pull on flexor tendons and show full flexion of both IPs, make sure no flexor tendon adhesions. -Volar Plate Avulsion Extension Contracture (see volar plate test). Operative RX: Reattachment of volar plate by formation of cancellous groove on volar proximal lip of middle phalanx, leaving volar plate attached to assembly line on 1 side. MCP CONTRACTURES: -Usually Extension Contracture -Non-operative RX: Knuckle-Jack. -Operative RX: Dorsal incision. Sagittal band hood fibers retracted distally, may need to cut, usually on ulnar side. Dorsal capsule transected and joint flexed. If collateral cannot pass over condyle, then transect at their attachments to the metacarpal heads. May need to free adhesions dorsal to volar plate with Freer. Knuckle Jack post-op. WRIST CONTRACTURES: -Treat underlying pathology 1st -Non-operative RX: Serial casting is initial approach: Heavy volar and dorsal splints, forceful molding. Patient to retape and tighten each day. Change Q3 days until correction done. Operate if fails. -Operative RX: Same whether extension or flexion or both contracture. Dorsal approach, dorsal capsulotomy. Volar approach, volar capsulotomy (save RSC, RL—avoid ulnar translation). May need to flexor slide or Z-lengthen flexor tendons. Serial cast post-op. BURN CONTRACTURES: See Chapter 64 TENOCAPSULITIS=chronic inflammatory process, usually MCP, usually after direct blow. HX: h/o trauma, activity pain. PE: tender joint, lack full F/E, thick capsule. RX: Conservative (rehab, NSAID‘s, cortisone) x 4 months; surgery if fails. SURGERY: Capsulectomy and extensor tendon repair through dorsal longitudinal approach. Ulnar sagittal band elevated, may need to partially incise. RSD: -2 phases: 1st is active, destroys tissue. 2nd is resultant fibrosis and joint contracture. Watson believes in treating in 1st phase with compression/traction program using The Dystrophile Device. Compression on floor, traction with weighted bag. See Chapter 21. Chapter 17 – Dupuytren’s contracture (D.A. McGrouther) =Proliferative fibrodysplasia of subcutaneous palmar connective tissue -Cause remains idiopathic -Usually seen in men between 40-60 years old -Ring and little finger most often involved, most commonly at MCP, then PIP, and rarely DIP (from retrovascular cord) -Usually bilateral but more advanced in 1 hand

-Can be associated with epilepsy, alcoholism, diabetes

-Worse prognostic factors: 1) early onset age, 2) other area involvement: dorsum of PIP joints (knuckle pads), dorsum of penis (Peyronie‘s disease), plantar fascia (Ledderhosen‘s disease), 3) female, 4) recurrent disease, 5) radial sided disease -Cell of origin unknown, but vascular pericyte suggested -PDGF-beta, interleukin-1, basic fibroblast growth factor, epidermal growth factor, connective tissue growth factor may have role. -May be from environmental influence PATHOANATOMY: Normal digital fascia that becomes diseased: pretendinous band, transverse fibers, spiral band, natatory ligament, lateral digital sheet, Grayson‘s ligament (but not Cleland‘s ligament). BAND is normal palmar fascial structure, and CORD is diseased band. -Central cord: central from pretendinous band, attached to base of middle phalanx. -Lateral cord: from natatory ligament to lateral digital sheet -Spiral cord: from pretendinous band, spiral band, lateral digital sheet, Grayson‘s ligament. With PIP contracture, NV bundle displaced toward midline, proximally, and superficially. RX: Non-operative: consider clostridial collagenase injection. No perfect operation. Indications: loss of function or progression of disease, no definite number in degrees, although if < 30 degrees, patient often made worse. OPERATIVE TECHNIQUES: SKIN MANAGEMENT May incise or excise skin (usually dermofasciectomy). INCISIONS: -Straight longitudinal line broken up by Z-plasties-most popular technique (McFarland, Hueston). Dissection starts distally or proximally. Z-plasties either at flexion creases or midway between (opinions vary). -Multiple Y to V advancement flaps- Bruner Zigzags with lateral limbs added -Moermans small curved incisions-along cord, excise intermittent lengths of cord -Transverse skin incisions-Dupuytren first performed in palm, McCash revised, now called open palm technique when skin is not closed. May cover with STSG or FTSG. EXCISION: Dermofasciectomy FASCIA MANAGEMENT -Limited fasciectomy- remove involved fascia. Go in proximal to distal direction or vice versa. Preserve fat on skin. -Radical fasciectomy- also remove cuff of normal fascia. Not widely used. -More limited fasciectomy- remove involved fascia with tension JOINT CONTRACTURE MANAGEMENT

-may need to release flexor tendon sheath, Grayson‘s ligament, check-rein ligaments, accessory collateral ligaments, then perform gentle manipulation. APM: To release MCP, transverse distal palmar incision, remove 1.5-2 cm longitudinal cord. To release PIP, dermofasciectomy in diamond shape over PIP, and skin graft. POST-OP: Splint 2-3 days (10 if skin grafted), either all joints extended, or safety position. Then active motion (with splinting between exercise & at night). COMPLICATIONS: 17% -digital nerve division 1.5% -artery division-RX: release tourniquet. If fingertip or flap not viable, perform arterial reconstruction. -buttonhole-may give inadequate skin flap perfusion -hematoma-use bipolar -RSD RECURRENT DUPUY‘S -50% after 5-10 years -much more difficult and risky surgery -accept 35 degrees correction, if unable, consider salvage: PIP arthrodesis through dorsal incisions with single longitudinal K-wire and interosseous wire loop. CHAPTER 18 - VOLKMANN’S CONTRACTURE (Tsuge) Defn: muscle necrosis and fibrosis and nerve degeneration after compartment syndrome -2 types: 1) ischemic from arterial injury 2) direct trauma (both lead to compartment syndrome) EARLY INJURY PHASE -central muscles more affected (FDP, FPL), followed by FDS, PT. Wrist F/E and BR least affected. -nerve degeneration ( sensory change and paralysis 2ND PHASE -Muscle and nerve regeneration if mild. If not, fibrosis and contracture. RX -fasciotomy early to avoid Volkmann‘s -MILD (LOCALIZED) TYPE=limited to FDP with flexion contracture of 2-3 fingers and no sensory change. RX: dynamic splinting, rehab. Surgery after 3 months if no better. Simple excision of localized fibrotic muscle or flexor tendon slide. TECHNIQUE: volar zig zag incision. Release median and ulnar nerves. Identify and protect brachial artery. Release flexors off their origin (PT, FCR, PL, FCU, FDS, FDP). Occasionally F/E fingers to determine site of contracture and amount of release, usually 2-3 cm. Fix muscle to periosteum and SQ tissue and transpose ulnar nerve anteriorly.

-MODERATE (CLASSIC) TYPE=FDP, FPL, FDS, wrist F. Flexion contractures of wrist, all digits, and claw hand. Sensory changes. Most commonly from SCH fx‘s. RX: As above, but release from radius too: PT, FPL. If weak DIP flexion, consider 2nd stage tendon transfers— usually BR to FPL and ECRL to FDP, suture with Pulvertaft‘s interlacing method. -SEVERE TYPE=muscle degeneration of all flexors, some extensors; severe contracture & neuro compromise. RX: Excision all degenerated muscle and neurolysis, tendon transfers at second stage (same as above). If no power source available, consider free muscle transfer (pec major, gracilis, semitendinosis) -OTHER PROCEDURES: pedicle skin graft, wrist fusion, CMC fusion, osteotomy of thumb metacarpal in opposition, nerve grafts.

Chapter 19 - Intrinsic contracture (Richard Smith) 1) ANATOMY (PP=proximal phalanx, MP=middle phalanx, DP=distal phalanx) a. Interossei and hypothenars. 7 interosseous muscles: 4 dorsal (abduct) and 3 volar (adduct). Dorsal interrosei (except of 3rd) have 2 heads: superficial inserts by medial tendon and abducts and weakly flexes PP, no effect on MP or DP. Deep head forms lateral band at MCP, it flexes and weakly abducts PP and extends MP and DP. At middle of PP, transverse fibers arch dorsally from each lateral band to join each other-it flexes PP. More distally, oblique fibers (spiral fibers) from lateral bands sweep over distal third of PP to insert onto lateral tubercles at MP base-they extend the MP. More distally, lateral bands join lateral slips of the extensor tendon to form the conjoined lateral band. 2 conjoined lateral bands unite at distal third of MP to form terminal tendon which inserts at base of DP to extend it. Abductor digiti quinti is like superficial head of dorsal interroseous, flexor digiti quiniti brevis like deep head. Volar interossei have 1 head, none insert onto PP. They are like deep heads. a. Lumbricals- arise from FDP. Only muscle that originates and insert on tendon. Tendon passes volar to MCP and joins radial lateral band at middle of PP—flexes MCP and extend PIP and DIP. a. Extrinsic extensors: 4 EDC, EIP, EDQ. In region of MCP, sagittal bands pass from extensors to volar plate and volar base PP-they extend PP when extensor contracts. Distal to MCP, extensor tendon divides into 3 slips. Central slip inserts onto base of MP and extends it. 2 lateral slips join lateral bands to make conjoined lateral band. Triangular ligament holds conjoined lateral bands dorsally. Laterally, transverse retinacular ligament prevents bowstringing of bands by extending from conjoined bands to fibro-osseous tunnel. 2) INTRINSIC MUSCLE CONTRACTURES (IC) a. Diagnosis: causes: trauma, inflammation, tumor, CNS disease, joint destruction. Intrinsic tightness (IT) test=PIP flexion less when MCP extended than when flexed. Cannot use IT test if PIP adhesions, MP non-mobile, extrinsic also tight. TYPES of IC a. IC with mallet finger

i. With rupture/avulsion of terminal tendon, conjoined lateral bands retract proximally and tension in central slip increased and PIP extends. Advance or repair terminal tendon to rebalance finger. a. Early post-traumatic IC i. From edema, prolonged immobilization, muscle ischemia. RX: decrease edema by elevation, avoid tight dressing/cast, measure compartment pressures and release prn. a. Late post-traumatic IC of PIP i. Extension contracture of PIP, and IT test positive. RX: Distal intrinsic release: longitudinal incision of dorsal midline of distal half of PP. Lateral band and oblique fibers resected at distal third of PP. MCP splinted in extension 3 weeks, IP flexion exercise at POD 1. a. Late post-traumatic IC of MCP & PIP i. If interossei retain contractility but are fibrotic and tight, they may be released with muscle slide. If they are necrotic and nonfunctional, then interosseous tendons should be transected proximal to MCP joints. If MCP remains flexed, accessory collateral ligaments divided at volar plate insertion, free volar plate from PP & MC bluntly. If passive PIP flexion incomplete with MCP extended, then do distal intrinsic release. a. Spastic IC (CP, CVA, CNS disease) i. Often both extrinsic and intrinsic spasticity; intrinsic not apparent until after extrinsic release. RX: muscle slide. Muscle origins of all interossei are stripped subperiosteally from proximal half of metacarpal shafts and abductor digiti quinti and flexor digiti quinti brevis are transected. MP extended and PIP flexed and held in this claw position for 3 weeks. a. RA IC i. MP: For ulnar drift, do crossed intrinsic transfer: transect ulnar interosseous tendons and transfer to radial side of base of adjacent PP. i. Swan-neck: can have several causes: Intrinsic tightness, PP subluxing volarly causing extensor tendon tightness, rupture of FDS, volar plate failure, rupture of terminal extensor tendon. If from intrinsic tightness, do intrinsic tenodesis: approach through dorsal curved incision, convex radially from DIP to MCP with apex at radial PIP. Ulnar lateral band transected at midshaft of PP. Lateral band and conjoined lateral band separated from central slip and freed to terminal tendon. Distal half of radial lateral band excised with oblique fibers. If cannot flex PIP 90 degrees, transect collateral ligaments. Curved hemostat passed volar to Cleland‘s ligaments at PIP. Ulnar lateral band passed volar to Cleland‘s . Transverse hole drilled through PP neck and lateral band passed through with PIP flexed 30 degrees. Hold with pull-out suture over button. If MCP volar subluxed of flexion contracture, divide transverse fibers and lateral tendon of ulnar interosseous muscle. Dorsal extension block splint at 30 degrees x 6 weeks, immediate ROM. If severe swan-neck and Cleland‘s too weak, then do spiral oblique retinacular ligament (SORL) construction: Volar zig incision with apex at radial PIP, distal limb to DIP dorsum. Do distal intrinsic release. Tendon graft (palmaris longus), sutured to terminal tendon or DP base and passed deep to NV bundles and superficial to flexor tendons across volar PIP. Drill hole transverse through PP neck and graft passed, held with pull-out suture over button with PIP at 30 degrees. Post op like intrinsic release. 3) Lumbrical contracture

a. If lumbrical fibrotic or contracted, force of FDP transmitted to lumbrical and get paradoxical extension: when attempt IP flexion, get IP extension. RX: lumbrical release: longitudinal radial midaxial incision made along PP. Radial lateral band and oblique fibers resected. Paradoxical extension also caused by: profundus laxity distal to lumbrical, shortened lumbrical, amputation of distal phalanx with retraction of FDP. CHAPTER 20 – DISTRACTION LENGTHING (Seitz) INDICATIONS – trauma, congenital absence. Use for slow distraction of soft tissue contractures such as in burn or radial clubhand. Other examples: gunshot wounds, short amputations (for prosthesis), phocomelia. -Patient must be compliant; long pre-op counseling RELATIVE CONTRAINDICATIONS -Single digit deficiencies (other than the thumb) -Forearm lengthening with stiff elbow -For cosmesis TECHNIQUES OF DISTRACTION LENGTHENING DISTRACTION OSTEOGENESIS (=CALLOTASIS) =slow distraction through an area of healing fracture callus -Pioneered by Ilizarov, Monticelli & Spinelli GENERAL TECHNIQUE -Preinsertion of fixation pins/wires -Local incision at site of osteotomy, careful elevation and preservation of periosteum -Controlled osteotomy and periosteal repair -Device assembly -Delay period for early healing, then slow distraction APM: HALF-FRAME LENGTHENING BY CALLOSTASIS PIN PLACEMENT/DEVICE ORIENTATION HUMERUS -Half-pin monolateral frame configuration -Can also lengthen a very short humeral amputation stump to facilitate better prosthetic fitting

FOREARM -Indications: radial agenesis, multiple heredity exostoses, Madelung‘s deformity, physeal growth arrest, short amputation stump -May use circular fixation to correct angular deformity. However, equally efficacious and less complex to perform angular corrective osteotomy followed by lengthening along a single axis -Pin placement: radial aspect of radius, ulnar aspect of ulna

-For very proximal stump lengthening, stabilize the elbow joint with a third set of pins -For distal lengthening, stabilize hand (especially in radial clubhand) with a 3rd set of pins METACARPALS/PHALANGES -Dorsal oblique half-pin placement -Individual finger devices -Can lengthen across MCP joints DEVICE CHOICE (APM) -Predrilled, threaded, self-tapping half-pins in monolateral configuration -HOWMEDICA: Monotube spring-loaded lengthening apparatus, small Wagner lengthener, mini-Hoffman lengthener for fingers -EBI: Orthofix small lengthener SURGICAL TECHNIQUE SKIN INCISION -Longitudinal incision is made over pin sites, slightly longer that 2 pin spread -bluntly spread down to periosteum; sharply incise periosteum -Directly visualize contour of bone to centrally drill PIN/DRILL SIZES -Humerus: 3.2 mm drill, 4 mm pin -Forearm: 2.0-2.5 mm drill, 3mm pin -Metacarpals and phalanges: 1.5 mm drill, 2mm pin OSTEOTOMY -At central point between 2 sets of pins, incise periosteum and carefully elevate circumferentially, Bennet retractors placed -Osteotomy performed with osteotome; do not use saw (heat injures bone) -Preferable site of osteotomy is metaphyseal (heals faster) but may be diaphyseal CLOSURE -Close periosteum with 6-0 absorbable suture LENGTHENING PROCESS -Start on 5th day post-op for children, 7th day for adults -4 daily increments of 0.25 mm each done at breakfast, lunch, dinner, bedtime -Records kept PIN CARE (APM) -BID H2O2 on sterile Q-tip x 1week, then as above but with alcohol and allow shower QD COMPLICATIONS -Pin tract infections, stiffness -Joint subluxation/angular deviation. To avoid these, control adjacent joints by incorporating them in the ex-fix, release contractures before lengthening, lengthen over a central guide wire -Premature consolidation usually from inadequate patient education or noncompliance -Failure of consolidation from rough soft tissue handling, dysvascular bone, too rapid lengthening, unstable fixation

-Fracture through new bone/pin site. To avoid this, need x-ray consolidation of 3 cortices before device removal. Device should be maintained for 2x lengthening duration in children; 3x for adults -Pain from nerve stretching, transient local infection, soft tissue tension -Distal soft tissue erosion. Avoid by careful monitoring, possible pre-op flap coverage -Physeal injury: Careful pin placement important. Can lengthen through physis, but reserve this for children near maturity because physes close after lengthening CHAPTER 22 – ELBOW CONTRACTURE (Robert Hotchkiss) HISTORY: -Age: Best success of RX 18-50 y.o. -Timing: Most patients do not improve after 6 months post injury (except pedi supracondylar fxs). At the 6-8 month mark, unless significant brain injury, the HO is matured and can safely be removed without recurrence. -Pain: Pain at end range, but otherwise not very painful. EXAM: -Lack of extension easier tolerated -ROM: If in 40-105 degree range, consider for release. IMAGING: -X-rays: Answer: 1) Are fractures healed? 2) Is hardware impeding motion? (need removal?) 3) Where is HO? 4) What is quality of joint? OA? -Consider lateral max flex/ex views -May need CT to better answer PREOP DISCUSSION AND PLAN: -High risks, could worsen. Full motion usually not achieved. -Given complexity and risk of surgery, do not generally recommend release for cosmesis

ARTHROSCOPIC RELEASE: -Works best in young athlete with loose bodies or h/o hyperextension and minimal contracture. Also for middle-aged 45-55 y.o. with OA and simple osteophytes at coronoid and olecranon. -Should not be performed if ulnar nerve transposition needed or if posteromedial osteophytes OPEN RELEASE: -Either medial or lateral approach; should know both -Approach where problem is; medial if need ulnar nerve transposition -Protect anterior medial ligament and posterolateral ligaments MEDIAL “OVER THE TOP” APPROACH (HOTCHKISS): -Supine, hand table, move patient as far as possible onto hand table, prep to axilla, sterile tourniquet

-Medial incision, elevate SQ skin, identify medial supracondylar ridge, medial intermuscular septum, origin of flexor-pronator muscle mass, ulnar nerve. -ANTERIOR: Medial antebrachil cutaneous nerve is anterior to septum—protect, may have to sacrifice -as far proximally as possible. Protect ulnar nerve. Excise medial intermuscular septum from supracondylar ridge to proximal extent of wound. - Flexor-pronator mass divided parallel to its fibers, with 1.5 cm FCU left on epicondyle. May need to incise lacertus fibrosis. Start at supracondylar ridge and elevate anterior muscle with wide Cobb elevator. Median nerve, brachial artery and vein are superficial to brachialis. Place wide Bennett. -Flex/ex elbow and feel for coronoid (will feel deep and distal). Place deep narrow retractor. -Sharply excise anterior capsule. Stay deep to muscle (radial nerve runs between brachialis and brachioradialis) -POSTERIOR: Move ulnar nerve anteriorly. Start at supracondylar ridge and elevate triceps with wide Cobb elevator, place wide Bennett. Excise posterior capsule. Remove HO, usually on olecranon and posteromedially. -Repair flexor-pronator mass with 0 ethibond. Transpose ulnar nerve anteriorly. LATERAL APPROACH (COLUMN PROCEDURE-MORREY): -Similar to medial approach, starting at lateral supracondylar ridge. Protect radial nerve. Anterior and posterior approaches. POST-OP: -Drain 2-3 days. First 24 hours: rest, ice, elevation. Sling above heart and pack in ice. If hinge fixator on, max tolerable extension and pack in ice. -APM: Rehab & CPM used as ―intermittent passive positioning‖—set CPM at max tolerable flex/ex and slowest setting, hold at max settings for 20-30 minutes each. At night, resting extension splint or turnbuckle splint (if > 30 degree flexion contracture) x 8-12 weeks. -APM: Indomethacin x 6 weeks, nothing if cannot tolerate. No radiation. EXPECTATIONS AND RESULTS: -Significant improvement in 90%. If < 40 degree flexion contracture, 5-10 degree residual contracture. If 50-105 stiff, expect 20-130. If < 40 degree total motion, goal 25-130. SPECIAL CIRCUMSTANCES: -Painful Hardware: Should be united before removal. Be ready to bone graft and re-plate in nonunion. Release contracture first, then HWR. -Nonunion of Distal Humerus: Release contracture first, then HWR, bone graft and re-plate. If elderly, consider total elbow replacement with semiconstrained implant (Coonrad-Morrey elbow) -Head Trauma and Brain Injury: Difficult, must at least be able for fire biceps and triceps on command. May help to position hands for transfer, use of motorized devices and self-care. HINGED FIXATION AFTER CONTRACTURE RELEASE (on for at lease 6-8 weeks): Reasons for use: -Instability After Release -Excessive Muscle Tightness -Distraction Arthroplasty

COMPLICATIONS: Nerve Palsies: Ulnar nerve-10% with dysfunction, most resolve in days-weeks. Radial & medial nerve. HO: Recurrent HO is rare Pin Tract Infections: 50-50 chance. RX: 7 day course Keflex (if not allergic) Joint Infection: CHAPTER 23 – Tennis elbow (Avrum I. Froimson) -epicondylitis, more common in non-athletes than tennis players -7-10 x‘s more often on lateral than on medial

-SYMPTOMS: tenderness and pain at humeral epicondyle aggravated by wrist extension if lateral and wrist flexion if medial, occasionally both -PHYSICAL EXAM: point of maximal tenderness at lateral epicondyle. Pain reproduced by resisting wrist and finger extension with elbow extended or passively flexing fingers and wrist with the elbow fully extended. -usually 4th-5th decades, not seen in young. If elbow symptoms in young, DDX: instability, osteochondritis dissecans, tumor. Other DDX: radial tunnel syndrome-pain and tenderness through muscle mass just distal to radial head. Pain reproduced by resisting middle finger extension or by forearm supination with the elbow extended. -PATHOLOGY: lesion is tear in common extensor or flexor origin at respective epicondyle, produced by mechanical overload in sports or at work in degenerating or aging tendon fibers. Tears range from microscopic to gross rupture or avulsion. -DIAGNOSTIC IMAGING: may show bony thickening or osteophytes, or poorly circumscribed soft tissue calcification. -NONOPERATIVE TREATMENT: initial period of rest, followed by stretching/strengthening rehabilitation of forearm and hand; NSAIDs; modalities (heating pad, ultrasound); forearm support band; water-soluble steroid/anesthetic injections (up to 3). -SURGICAL MANAGEMENT: INDICATIONS: if fail conservative treatment (5-10 %). ANATOMY: Lateral mainly ECRB from lateral epicondyle, radial collateral ligament, annular ligament. Medial mainly FCR, less FDS. -SURGICAL TECHNIQUE: excise damaged tendon fibers, repair the defect, and promote the firm reattachment to bone of the extensor or flexor origin. Specifically, tourniquet, supine, arm across chest. Longitudinal skin incision from 1 cm proximal to lateral epicondyle to 4 cm distal. Deep antebrachial fascia incised longitudinally and retracted. ECRB may be intact, may be edematous and hyperemic, or may be grossly disrupted or avulsed. Common extensor tendon is split by longitudinal incision and sharply dissected off the epicondyle 0.8 cm anterior and posterior. Necrotic and torn fibers, granulation tisse excised. With narrow osteotome, tip of lateral epicondyle (0.5 cm) excised to produce raw cancellous bone surface and permit

approximation of edges of debrided tendon over bone without tension. Elbow joint not intentionally entered, however if rent made, then the joint is inspected, and hypertrophic synovium excised. Then close joint with nonabsorbable sutures. Avoid radial collateral ligament injury, but if cut, repair. Close defect by suturing tendon to periosteum and triceps fascia. POSTOP: posterior splint from axilla to palmar crease with elbow at 90 degrees, forearm neutral, wrist slightly extended x 2 weeks, then move without resistance. Putty grip strengthen after 4 weeks, then resistive elbow/wrist flexion/extension exercises after 6 weeks, regular activity after 8 weeks. -SURGICAL RESULTS: 86% able to return to regular work, sport. -MEDIAL SIDE: supine, arm abducted on hand table. Surgery like for lateral side, but avoid ulnar nerve injury. Remove only very tip of medial epicondyle. Ulnar nerve transposition if nerve dysfunction. Chapter 24 – Compartment syndrome (Spencer Rowland) Compartment syndrome=group of symptoms and signs from increased pressure w/i a limited space compromising perfusion and function of tissues. Muscle and nerve can survive ischemia for 4 hours, but are irreversibly damaged after 8 hours. 1. Diagnosis-hallmark is pain-persistent, progressive, and unrelieved by immobilization. + passive muscle stretch test. Diminished sensation. Weakness and diminished muscle function. Palpation of compartments-tense and tender. Late in course, pain may decrease secondary to nerve damage. Measure pressure, + if >30 mm Hg if normotensive. If hypotensive, + if 20 mm Hg below diastolic. 2. Anatomy-forearm with 3 compartments: volar, dorsal, mobile wad. Hand with 10 compartments: 4 dorsal and 3 volar interossei, adductor pollicis, thenar, hypothenar. 3. Fasciotomy-perform if clinically suspect +/- with pressure test. a. Forearm: volar: start with carpal tunnel, transverse ulnarly over wrist crease, ―S‖ forearm proximally with small top portion, ulnar medial epicondyle flap, over brachial artery up arm. Dorsal straight longitudinal incision, release dorsal and mobile wad. b. Hand: 2 longitudinal dorsal incisions over 2nd and 4th MC‘s, open dorsal compartments, spread palmarly to release volar compartments. Thenar and hypothenar compartments opened from separate lateral incisions. Include carpal tunnel release. c. Finger: midaxial lateral incision over entire length of finger, over nondominant side - radial thumb and 5th, ulnar others. Spread across finger dorsal to NV bundle, palmar to flexor sheath. -After fasciotomy, inspect muscle. epimysiotomy if muscle is pale, tense, avascular. Do not debride muscle intially. Free median nerve from pronator teres and FDS. Do not close skin, but loosely cover nerves. Place safety splint and elevate. (Do not elevate a nondecompressed limb; this increases ischemia). Close skin after 5-7 days (do not close over necrotic tissue or with

excessive skin tension). Consider shoelace technique. STSG if can not close after 10 days. Warn patient of usual ugly, hypertrophic scars. Snake bits-98% form pit vipers (Crotalidae) which include rattlesnakes, cottonmouths, copperheads. 2/3 bites are in U.E. 1. Envenomation=enough venom introduced to cause effects. Venom has hemo, neuro, veno, cardiotoxins. Local effects:immediate edema and ecchymosis, severe pain. Systemic: bleeding disorders, pulmonary edema, N/V, weakness, sweating, paresthesias, fasciculations. 2. Treatment: A. Immediate-keep patient calm. Kill and retrieve snake if possible. Tourniquet immediately proximal to bite to occlude drainage but not A/V circulation, move proximally as swelling advances. Incision ¼ inch long and deep around fang marks and cup suction (can get 50% if done w/i 3 minutes, after 1 hour little value. Immobilize extremity. Do NOT use ice (adds to tissue damage). B. Hospital-identify snake (20% bites non-poisonous). Admit and observe all-23 hours. Tourniquet and suction. Labs. 2 IV lines, start fluids and give antivenin if signs of envenomation (test 1st for allergic reaction (23%), be ready for possible anaphylactic shock. Antibiotics, tetanus, possible blood/products. C. Surgery-controversial (some recommend to debride all, some not) APM: fasciotomy if compartment syndrome (measure compartments if difficult to tell) and minimal peri-bite debridement. No surgery if no compartment syndrome. Chapter 25 – Fractures of the Metacarpals and Phalanges (Peter Stern) 1) a. a. a. 2) a. a. a. a. a. a. a. a. a. a. Introduction Most common upper extremity fractures Thumb and 5th finger most common Peak incidence: 10 to 40 year-olds Indications for fixation Irreducible Malrotation Intraarticular Subcapital phalangeal Open Segmental bone loss Polytrauma with hand fractures Multiple hand or wrist fractures Associated soft tissue injury (vessel, tendon, nerve, skin) Reconstruction (i.e., osteotomy)

Metacarpal Fractures (Excluding the Thumb) 1) a. a. Metacarpal head fractures Rare, usually intraarticular Mechanism: axial load or direct blow

a. Radiographs: PA, lateral, oblique of hand; possibly add skyline metacarpal view: fist, beam parallel to dorsal proximal phalanx. CT may be helpful. a. TREATMENT i. Non-operative: if non-displaced-> Safety position splint for 3 weeks i. Operative: if >25% of articular surface, >1mm step-off a. SURGICAL OPTIONS - CRIF vs. ORIF i. Screw preferred: rigid fixation, early motion; K wires, cerclage wire 1. Displaced 2 part fx: ORIF with Herbert screw: Dorsal longitudinal incision, split extensor tendon, expose joint i. Ex fix - Considered if associated comminuted fracture of proximal phalanx base i. Silicone arthroplasty - Considered if open, comminuted, bone loss 1. Comminuted intraarticular fractures: ORIF very difficult. APM: immobilize 2 weeks, then ROM. Consider ex-fix or silicone arthroplasty. i. MCP arthrodesis - Salvage, not done acutely a. Special consideration: Open fracture associated with human bite i. Usually from punch to mouth i. Needs irrigation and debridement, antibiotics i. Leave wound open, delayed fixation after wound is clean a. Complications i. Most common: stiffness, from 1) Extensor tendon adhesions, 2) Contracture of collateral ligaments or dorsal capsule, 3) Articular incongruity 2) Metacarpal neck fractures a. Usually involve ring or small metacarpal, ―Boxer‘s fracture‖ – misnomer a. Apex dorsal angulation because 1) Dorsal impact and volar comminution, 2) Intrinsics volar to MCP axis a. Treatment - Most can be treated non-operatively i. Reduction indicated if 1. ―pseudoclawing‖=compensatory MP hyperextension and PIP flexion on attempted finger extension 1. > 15o angulation in index and middle, 30-40o in ring, and 50-60o in small fingers 1. malrotation i. Reduction technique: Hematoma or wrist block, Jahss maneuver: flex MP & PIP 90o, reduce angulation & rotation, Ulnar gutter splint in safety position x 3 weeks i. If reduction unacceptable or cannot maintain, 1. CRIF: Crossed K-wires, inserted into non articular head to shaft; or Percutaneous Kwires inserted head to head 1. ORIF: Crossed K-wires +/- Dorsal tension band wire, or Lateral minicondylar plate a. Complications: Malunion: Loss of head prominence, Decreased ROM, Palpable head in palm, malrotation 3) Metacarpal shaft fractures

a. Most can be managed closed. If stable and non-displaced, buddy tape and clam-digger cast x 3-4 weeks; immediate finger motion a. CRIF indicated if cannot maintain a reducible fracture or if concomitant soft tissue injury precludes casting a. ORIF indicated if i. Residual angulation 10o – 2 & 3rd metacarpals, 20o – 4th metacarpal, 30o – 5th metacarpal i. Malrotation (usually spiral or oblique fractures) i. Multiple fractures i. Open fractures with soft tissue injury or bone loss i. ORIF exposure: Longitudinal incision – either between metacarpals 2 & 3, or 4 & 5. Preserve dorsal sensory nerves, paratenon, junturae tendinum. May divide junturae tendinum for exposure – repair after fixation. i. Fixation options: K-wires, Composite wiring (combination of interosseous wire 24-26g and K-wires 0.035-0.045in), IM rod, Multiple interfragmentary screws, Plate and screws, Ex fix a. Transverse / short oblique shaft fractures i. Mechanism: axial load or direct blow. Apex dorsal: interosseous deforming force. i. Treatment: Usually easy to reduce (Jahss method), but may be difficult to maintain. Watch for malrotation. Hold with safety splint, x-ray weekly. Guarded AROM may start at 3-4 weeks. i. If CR unsuccessful, CRIF with transverse K-wires to intact adjacent metacarpal or retrograde IM fixation; or ORIF with composite wiring i. For Multiple open transverse/short oblique fractures, ORIF with IM nail (K-wires or Steinman pins). Rotational stability may be problematic – may add transverse pin. SURGICAL TECHNIQUE: IM NAILING OF METACARPAL (best for transverse of short oblique fracture) -Either with 0.035 inch (0.8 m) K-wires or Hand Innovations IM nail set -K-WIRE TECHNIQUE: Approach base of metacarpal dorsoradially or dorsoulnarly. Make 2.5 mm drill hole at base of metacarpal. Pre-bend K-wire (hook at end and catenary bend throughout). Introduce 1-3 K-wires through hole, insert to distal end of metacarpal; goal is 3 point fixation. Cut off short flush to bone; no need to remove. Confirm no malrotation clinically. Place dorsal hand splint (x 3 weeks) up to metacarpal heads and buddy tape; allow immediate motion. a. Spiral and long oblique fractures i. Mechanism: torsion. May cause malrotation. Assess clinically with half-closed fist. 3-4 mm shortening is maximal limit. i. If CR unsuccessful, may ORIF with interfragmentary screws. Fracture length should be at least twice and preferably 3x‘s the bone diameter. 2.0 and/or 2.7 mm screws. Screws should be inserted a minimum of 2 screw diameters from the fracture line & bisecting the bone‘s longitudinal axis and fracture plane. i. If Bony loss or comminution with soft-tissue injury, malunions, or pseudarthrosis, ORIF with plate and screws. Must engage 4 cortices, both proximal and distal. Bulk may require secondary

hardware removal. If cannot cover with soft tissue -> external fixation. a. External fixation indicated for Open fractures with or without bone loss, Loss of soft tissue, Septic non-union. a. Segmental metacarpal loss: Thorough I&D, then ex-fix. Additional I&D over 3-5 days until clean, then ICBG and dorsal plate; single bone block if multiple metacarpals involved. Soft-tissue coverage with regional, distant, or free flap. Staged tendon reconstruction with silicone rods inserted when flapped, and replaced later with free tendon grafts. 4) Metacarpal base fractures and CMC fracture-dislocations a. Avulsion fractures of 2nd & 3rd MC bases. i. Rare. Lack of motion at these joints. Mechanism: fall on palmar flexed wrist. Treatment controversial: operative vs. non-operative a. Fracture dislocations of 4th and 5th CMC joints. i. Common. Mechanism: longitudinal force. Displacement proximal and dorsal metacarpal subluxation. Frequently missed on routine x-rays-add 15o obliques from lateral and potentially CT. Inherently unstable: need CR-PCP vs ORIF. Multiple CMC fx-dislocations->ORIF. a. Symptomatic post-traumatic OA. RX: arthrodesis with corticocancellous slot graft (ICBG), fixed with K-wires or plate. Does not significantly compromise function. 5) Complications of metacarpal fractures a. Malunion-dorsal angulation: May cause grip weakness, painful gripping with metacarpal head in palm, pseudoclawing. May need surgical correction: closing or opening wedge osteotomy. Fix with K-wires, composite wiring, or dorsal plate. a. Malunion – malrotation: May cause digital overlapping and weak grip. RX: Corrective de-rotation osteotomy. a. Nonunion: uncommon. Usually secondary to bone loss, osteomyelitis, inadequate immobilization , or poor fixation. Atrophic (usual) treated by pseudarthrosis resection, bone graft, stable fixation. Infected nonunion treated by I&D, ex-fix, coverage, later (4-8 weeks, when clean), bone graft and fixation. a. Tendon adhesions. Treat with therapy and dynamic MP flexion splinting; if fails, tenolysis with possible capsulotomy. a. Loss of intrinsic muscle or denervation. May lead to clawing and require tendon transfers. a. Intrinsic contractures. May require releases.

Phalangeal fractures 1) Distal phalanx fractures a. Most common fracture in hand a. Classified as tuft, shaft, or articular a. Tuft fractures - Usually from crushing injury. Often with painful subungual hematomadecompression provides dramatic pain relief. Perform with sterile needle (18g), battery electrocautery or heated paper clip. 3 weeks immobilization, do NOT include PIP. Rarely require CR-PCP. Repair pulp lacerations with 4-0 or 5-0 nylon, nail bed lacerations (after nail removal) with 5-0 or 6-0 chromic, replace nail or xeroform under eponychium. a. Tip amputation. RX: Let heal by secondary intention if no exposed bone. If exposed bone, rongeur back so no exposure.

a. Shaft fractures. Non-displaced: immobilize 3 weeks, PIP free. Displaced: may need longitudinal K-wire or Herbert screw. a. Articular fractures. i. ADULTS: Dorsal mallet fractures, Volar profundus avulsions i. CHILDREN: adolescents - SH III, preadolescents - SH I & II 1. May be mistaken for open DIP dislocation. Failure to treat may lead to short digit & decreased DIP ROM. 1. Seymour fractures = open epiphyseal distal phalanx fracture. RX: usually in OR, I&D, fx reduction, nail bed repair, replace nail under eponychium, splint. a. Complications i. symptomatic nonunion. RX: crossed K-wires and bone graft through palmar midline approach. i. Malunion rare. RX: osteotomy i. Nail bed deformity 2) Middle and proximal phalanx fractures a. Nondisplaced and stable. RX: buddy tape/splint 3 weeks (definitely no more than 4 weeks to minimize stiffness). Immobilize joint above and below. Then buddy tape and AROM. Articular fractures a. Condylar fractures: Unicondylar,

bicondylar, or comminuted. i. Even initially nondisplaced fractures are inherently unstable and will eventually displace. Therefore, RX: ORIF (standard) vs CRIF. Fixation with multiple K-wires, mini-screw(s), or combination. Unfortunately, regardless of fracture pattern or fixation, FROM unlikely secondary to extensor lag and/or flexion contracture. i. ORIF: Exposure through dorsal radial or ulnar longitudinal incision. Joint entered between central slip and lateral band; do not detach central slip or collateral ligament. Clean fracture, reduce, clamp, fix, repair dorsal apparatus. Post-op: AROM, splint in extension, d/c Kwire at 3-4 weeks. If significant comminution, may need supplemental cancellous bone graft. If reduction still impossible, consider dynamic external fixation. a. Collateral ligament avulsion fractures of the head. i. If displaced, may lead to symptomatic non-union, or pseudoboutonniere deformity (adhesions between lateral band, oblique retinacular ligament, and volar plate). Consider CRIF vs ORIF. a. Base fractures - Avulsion fractures of the dorsal base of the middle phalanx. Represents detachment of central slip. Mechanism: anterior PIP dislocation. RX: if >2mm displacement, needs CRIF vs ORIF to prevent extensor lag and Boutonniere. Technique: pin fracture and hold joint reduced with transarticular pin x 3 weeks. a. Base fractures - T-type. Often require ORIF. Dorsal tendon splitting approach. Fixation with K-wires or minicondylar plate.

a. Base fractures - Comminuted intraarticular fractures termed pilon fractures. Consider dynamic external fixation, and possibly additional limited open reduction and bone grafting. a. Fractures of lateral volar base - Represent collateral ligament avulsion injuries. RX: ORIF vs CRIF if significantly displaced with K-wire of tension band. a. Plateau compression fractures. Consider CT to evaluate articular depression. May need bone graft with ORIF. a. Physeal fractures i. Extraarticular (SH I, II). 85-90% of physeal fractures. RX: CR, splint. i. Intraarticular (SH III, IV). More common in proximal phalanx – collateral ligament attaches only to epiphysis in proximal phalanx, extends beyond epiphysis in middle. RX: ORIF vs CRIF. Approach proximal phalanx through dorsal tendon-splitting incision. Approach middle phalanx laterally between transverse retinacular ligament and dorsal apparatus. Nonarticular fractures of phalanges a. Neck fractures i. Often head rotates 90o and articular surface faces dorsally. Volar plate may be interposed and prevent reduction. RX: CR, splint vs CRIF vs ORIF. May need to open between central slip and lateral band and remove interposed volar plate. Fixation with crossed K-wires or mini-plate if comminuted. i. Complication – malunion with volar spike blocking ROM. May require ostectomy through lateral approach. a. Shaft fractures i. Transverse, oblique or spiral, comminuted i. Nondisplaced and stable or stable after closed reduction. RX: buddy tape and safety splint x 3weeks, then buddy tape 3 weeks. i. Displaced, unstable spiral and oblique fractures. RX: CRIF. Longitudinal traction, reduced and clamped, fixed with percutaneous K-wires. Proceed to ORIF if unable to CRIF in 23 attempts. Expose through straight longitudinal incision. Proximal phalanx approached through longitudinal tendon splitting incision. Middle phalanx approached by dividing transverse retinacular ligament at dorsal apparatus insertion and mobilizing dorsal apparatus. Fixation with K-wires or screws. If screws used, rule of 2‘s: fracture length at least twice bone diameter, minimum 2 screws, insert at least 2 screw diameters from fracture edge. i. Displaced and unstable transverse fractures. RX: CR, PCP – K-wire through flexed MP or PIP joint, reduce fracture, then drive to subchondral bone. Does not provide rotational control, so need 2 weeks immobilization, but simple & effective and APM. CR, PCP cross pinning frustrating and NOT recommended. RX: ORIF – if associated injuries require stable fixation or CR unsuccessful. Retrograde cross pinning method preferred. RX: ORIF – another method( cross pinning a reduced fracture (more difficult than previous technique). RX: ORIF – another method( interosseous wires (25 or 26 gauge) with possible supplemental K-wire. i. Displaced, unstable, comminuted. RX: mini-external fixator or plate/screws. 3) Open fractures

a. Antibiotics: At least 24 hours 1st generation cephalosporin, add aminoglycoside and PCN if grossly contaminated or delayed treatment a. Swanson Type I: clean, no delay treatment, healthy patient ( primary closure a. Swanson Type II: grossly contaminated, delay > 24 hours, systemic illness(delayed closure 4) Complications of phalangeal fractures a. Malunion i. Malrotation – may need osteotomy, fixation with K-wires or plate i. Volar, lateral angulation – may need closing or opening wedge osteotomy, especially if angulation > 25-30o i. Shortening – restoration of length alone rarely indicated, unless also with significant rotatory or angular deformity i. Intraarticular incongruity– osteotomy(in young patients with no OA), arthrodesis, or arthroplasty. a. Nonunion i. Uncommon. RX: surgical resection of nonunion, possible bone graft, K-wire vs plate. a. Loss of motion. Due to tendon adhesions and/or capsular contracture, intraarticular incongruity. Contributing factors: immobilization > 4 weeks, joint injury, crush, >1 fracture per finger, soft tissue injury. RX: hand therapy (A&PROM, dynamic splinting, compression). Surgery if plateau with conservative. Surgical treatment: extensor tenolysis over proximal phalanx. If PIP passive flexion still < 90o, then dorsal PIP capsulotomy. Active F/E; if passive flex>active flex, then flexor tenolysis. If severe contracture, consider PIP fusion or ray deletion. a. Infection. RX: I&D, abx, fracture stabilization (consider ex fix), later bone grafting. If cannot eradicate, and left with painful, stiff, useless digit, consider amputation.

Thumb fractures • • • • • More forgiving of residual deformity than fingers secondary to compensatory motion Malrotation rarely a problem Acceptable angulation Frontal plane: 15-20o Lateral plane: 20-30o

1) Extraarticular phalangeal - Distal phalanx – tuft, transverse, longitudinal a. Tuft: Usually comminuted. Frequently associated with nail matrix and/or pulp injury. Rarely requires reduction or fixation. RX: Evacuate painful subungual hematomas. Repair lacerations as needed. Splint 3-4 weeks. a. Transverse. Potentially unstable. Apex anterior angulation from FPL. If cannot hold reduction in splint, longitudinal K-wire into proximal phalanx. a. Longitudinal. Uncommon. If displaced, clamp and pin. 2) Extraarticular phalangeal - Proximal phalanx. RX Principles similar to in fingers. 3) Metacarpal fractures a. Shaft fractures – uncommon a. Extraarticular base fractures common=epibasal. Usually transverse or mildly oblique. Apex dorsal, distal fragment is adducted, flexed, and supinated. RX - CR: longitudinal traction,

downward pressure on apex, pronation, thumb extension. Usually stable in thumb spica cast. If > 30o, then CR, PCP. a. Bennett: intraarticular base fractures – fracture / subluxation with volar ulnar fragment anatomic and held by anterior oblique ligament. RX: if fragment 15-20% of articular surface, CR, PCP. CR: longitudinal traction, downward pressure on base, pronation, thumb extension. If CR, PCP not anatomic, or fragment > 25-30%, then ORIF. Approach between APL and thenar muscles. Complications: Malunion( osteotomy, arthrodesis. a. Rolando = any comminuted intraarticular base fracture. CT may be helpful. 3 part: ORIF with K-wires or plate, possible bone graft. Significant comminution: consider external fixation, K-wires, bone grafting. CHAPTER 26 – DISLOCATIONS AND LIGAMENT INJURIES IN THE DIGITS (Glickel, Barron, Eaton) PIP ANATOMY -collateral ligaments: 2-3 mm thick, originate from lateral aspects of condyles. Proper collateral ligament inserts on volar 1/3 of base of middle phalanx. Accessory collateral ligament inserts on volar plate. Volar plate is floor of joint, collaterals and volar plate form a box. EVALUATION OF PIP – AROM (check for stability in FROM), varus / valgus stress at 0 & 30 degrees, dorsal and palmar translation. DISLOCATIONS OF PIP –may dislocate dorsal, lateral, volar (refers to position of middle phalanx) ACUTE DORSAL PIP DISLOCATIONS –mechanism: axial compression and hyperextension. Type I (hyperextension) – PIP locked in 70-80 degrees hyperextension Type II (dorsal dislocation) – bayonet opposition Type III (fracture-dislocation) – Stable: < 40% articular surface. Unstable if > 40%. RX: For types I – III-stable, RX is CR. Maneuver: traction, flexion. Re-examine for stability. Buddy tape and extension block splint at point short of redisplacement and extend 10-15 degrees per week. Open reduction needed (rarely) if CR unsuccessful (volar plate interposed). Type IIIunstable usually needs ORIF. TECHNIQUE-ORIF: radially based volar zig-zag incision, excise flexor sheath between A2 & A4 and retract tendons. Hyperextend to see fragment & excise collateral ligaments attached to fragment. Fix with 0.028-inch K-wires or mini-fragment screw. If fracture too comminuted, then volar plate arthroplasty TECHNIQUE-VOLAR PLATE ARTHROPLASTY: Loose fragments debrided, defect shaped into transverse groove. Interval between VP and collaterals incised and plate mobilized 4-6 mm into defect, and held with pull out sutures out the dorsum of the middle phalanx. DIP flexed 30 degrees as suture passed. Repair VP/collateral interval. Move DIP immediately; longitudinal Kwire through PIP at 20 degrees flexion x 3 weeks. Full active extension at 4 weeks, may need dynamic splinting if active extension not full at 5 weeks. 6-8 months for final ROM.

CHRONIC PIP SUBLUXATIONS (HYPEREXTENSION OR SWAN-NECK DEFORMITY) -From untreated Type I dorsal PIP dislocation. HX: pain as lateral bands snap dorsally and volarly around condyles. PE: swan neck. Hold PIP in extension-if unable to extend DIP, then extensor problem. If able to extend DIP, then problem is volar support and RX surgical TECHNIQUE-SUPERFICIALIS TENODESIS: Expose A1 pulley through palmar incision. Transect radial slip of FDS as proximally as possible. Expose PIP through volar zig-zag incision. Make a bony tunnel in the proximal 1/3 of the proximal phalanx from ulnar to radial. Pass the radial FDS slip under the ulnar slip and through the bony tunnel from ulnar to radial (avoid injury to the ulnar slip‘s vinculum). Suture the FDS slip to the periosteum at the tunnel entrance and exits. Adjust the tension so the PIP cannot be extended past 5 degrees. If there is extra FDS slip length, then suture it to the volar plate for reinforcement. Use dorsal extension block splint at 5 degrees for 6 weeks. CHRONIC PIP FX/DISLOCATIONS APM Volar plate arthroplasty (see above). May require fractional lengthening of proximal check rein ligaments by making several 2-3 mm incisions. Completely excise PIP collateral ligaments. May need to release dorsal capsule. LATERAL PIP DISLOCATIONS Exam: Varus-valgus stress of PIP joint at full extension: >20 degree angulation indicates complete rupture of 1 collateral ligament and at base partial avulsion of the volar plate Treatment: Closed reduction and check for stability in flexion / extension; along with x-ray evidence of congruous reduction. Then same as stable dorsal dislocation VOLAR PIP DISLOCATIONS -Rare injury -Mechanism: rotatory longitudinal compression on a semiflexed middle phalanx results in unilateral disruption of collateral ligament and partial avulsion of volar plate. The condyle may rupture between central slip and lateral band in a buttonhole fashion which may block reduction. The central slip may rupture and be interposed, along with a collateral ligament or fracture fragment. -TREATMENT (APM): Closed reduction is usually successful with this maneuver: (1) digital block, (2) flex the MP and PIP joints, extend the wrist, (3) apply gentle traction and rotary motion to the middle phalanx, (4) once reduced, test for active motion and obtain x-rays to confirm congruous reduction. Full active extension is usually possible; if not, then immobilize PIP in full extension and treat as in boutonniere. -Open reduction if CR unsuccessful: Wrist block. Midaxial incision of side of major ligament disruption. Extricate lateral band (and any other interposed tissue) from joint and reduce. Repair lateral band if able; otherwise excise if irrepairable (contralateral lateral band will provide intrinsics). Test for active extension; if intact, then dynamic extension splint. If not intact, then treat as in boutonniere. POST-TRAUMATIC FIBROSIS OF PIP -An inevitable consequence of PIP dislocation

-Evolves in as long as 10-12 months -To minimize fibrosis, start motion as soon as possible; this can usually be immediate ROM avoiding the arc where resubluxation occurs -Systemic steroids 4 weeks after dislocation may be considered (prednisone 5 mg PO QID x 4 days, tapered 5 mg / day for 3 days) -If significant loss of motion (<60 degrees) persists despite dynamic splinting and rehabilitation, consider surgery. SURGICAL TECHNIQUE APM: PIP COLLATERAL LIGAMENT EXCISION (Eaton) -Digital block, brachial tourniquet -Approach PIP through bilateral mid-axial incisions, preserve dorsal sensory nerves -Lateral bands congealed in scar superficial to thickened collaterals -Oblique incision parallel to lateral bands midway between dorsal and volar borders of lateral band scarring -Thickened extensor mechanism (including oblique and transverse retinacular fibers) peeled dorsally and volarly sharply to reveal collaterals -Excise collateral sharply dividing proximal origin from condylar fossa (distally insertion of middle phalanx -Do UCL first, then AROM, do RCL prn -If extension not full, open flexor sheath at middle phalangeal base and release distal insertion of volar plate -Other possible structures to address: 1) tight dorsal capsule, 2) limited extensor or flexor tenolysis -Post-op: AROM POD 1, dynamic splint < 7days FINGER DIP AND THUMB IP JOINT DISLOCATIONS -Not as frequent as PIP -Usually dorsal or lateral -Often associated with open wound because of snug skin TREATMENT: Digital or wrist block. Closed reduction with longitudinal traction, direct pressure on distal phalanx and distal phalanx flexion -If open, thorough irrigation and debridement in O.R. or E.R. -After reduction, joint stability tested by ROM and varus / valgus stress. X-Rays to confirm congruous reduction. For rare post-reduction instability, immobilize in 20 degrees flexion with dorsal splint for 10-21 days; convert to dorsal block splint (@20 degrees) and start AROM. -Rarely irreducible; requires surgical extrication of interposed tissue: volar plate, tendon, fracture fragment, sesamoid. -Rarely, associated volar lip fracture of distal phalanx. If FDP avulsed, needs surgical reattachment. In not avulsed, closed reduction usually adequate. -Volar dislocations are rare; may need treatment as mallet finger FINGER MCP JOINT DORSAL MCP SUBLUXATION / DISLOCATIONS -Relatively uncommon. Most frequently index, followed by small finger -Mechanism: hyperextension. Volar plate ruptures and becomes interposed SUBLUXATION

-Volar plate remains with proximal phalanx -60-80 degrees hyperextension -TREATMENT: CR-Reduction maneuver: Flex wrist, apply distal and volar directed pressure to base of proximal phalanx. Immediate ROM with dorsal extension block splint at 0 degrees. Do not hyperextend during reduction; this can convert a subluxation to dislocation DISLOCATION -Presents in slight extension; flexion is impossible. Prominence in palm is metacarpal head. Widened joint space on x-ray -TREATMENT: Open reduction through dorsal incision (not palmar incision. NV bundle at risk). Reduce interposed volar plate palmarly and reduce joint. No need to repair volar plate. Dorsal extension block splint at 10 degrees x 4-6 weeks. VOLAR MCP DISLOCATIONS -Extremely uncommon. Attempt closed reduction. If fails, open reduction through dorsal approach (dorsal capsule and/or volar plate may be interposed) ISOLATED RCL INJURY OF MCP -Uncommon -Mechanism: forced ulnar deviation with MP flexed -TREATMENT: If not grossly unstable, then immobilize in 30 degrees x 3 weeks, then buddy tape 3 weeks. Usually successful, but pain may persist x 1 year; if continues to persist, consider ligament reconstruction. If grossly unstable, consider ligament repair LOCKED MCP -Uncommon -Presents with moderate flexion deformity of MP; IP function normally (as opposed to trigger digit) -Usual cause if impalement of collateral ligament by either osteophyte in older patient with OA, or prominent radial condyle in younger patient -TREATMENT: Insulfate joint with lidocaine to disengage collateral. If fails, surgically explore and remove osteophyte or condylar margin. FINGER CMC JOINTS -CMC fracture-dislocation is more common than pure dislocation -Most frequently 5th CMC -May miss on x-ray; important to obtain 30 degree pronated lateral view TREATMENT (APM): -Closed reduction, percutaneous pinning. Open reduction if unable to achieve closed. -Technique of closed reduction: Traction, manipulation. Flex wrist. Hold reduction with K-wire placed retrograde from MC head to carpal bone and out dorsal skin. Splint x 4 weeks. -Complications: OA (pain & weakness). If severe, consider CMC fusion or interpositional fascial arthroplasty THUMB MCP

ANATOMY: Collateral ligaments pass obliquely and volarly to insert on volar 1/3 of proximal phalanx. Accessory collateral more volar and inserts on volar plate and sesamoids; tight in extension, loose in flexion. Proper collaterals more tight in flexion, loose in extension ACUTE THUMB UCL INJURY -Common -UCL 10x more common than RCL -Mechanism: ski pole, ball, fall -Associated injuries: dorsal capsule, volar plate, avulsion fracture -May have volar subluxation -Tear at insertion 5x more common than proximal tear -Stener lesion (1962): adductor aponeurosis interposed between distally avulsed ligament and its insertion into proximal phalanx base. Only occurs in complete ruptures (Stener lesion in 25 of 39 cases, 64% incidence, of complete ruptures; Stener JBJS 1962) -Exam: Tender at UCL. Radial stress at 0 degrees extension. Complete rupture if opens 30 degrees or >15 degrees vs. contralateral side. May need to inject local anesthesia if too painful to stress fully TREATMENT: -Partial rupture treated with thumb spica cast (IP free) x 4 weeks, then AROM with removable splint x 2 weeks. No strenuous activity x 3 months -Complete rupture: operative repair SURGICAL TECHNIQUE: -Dorso-ulnar ―lazy S‖ incision (dorsal at proximal aspect, curves volarly distally to mid-axial aspect. Watch for superficial radial nerve) -Incise adductor aponeurosis longitudinally, parallel and just palmar to EPL -Inspect capsule (frequently with dorsal tear) and joint -Find site of UCL insertion (palmar) and roughen with curette -Repair UCL with mini-Mitek (check placement with fluoro). If mid-substance, repair with 4-0 absorbable suture. Excise small bone fragments, fix large ones with 0.045 K wire -With 4-0 absorbable suture, repair UCL to palmar plate, repair dorsal capsule, and repair adductor aponeurosis. -Gentle stress test -Close skin -TSS (with IP free) x 1-2 weeks, then SATSC x 4 weeks, then removable splint 3 weeks, F/E MCP

-No regular use for 12 weeks CHRONIC THUMB UCL INJURY (=Gamekeeper‘s thumb) -Campbell (1955) described in Scottish gamekeeper‘s attenuated UCL by fracturing rabbit‘s necks -Cause of chronic instability: as above, plus lack of successful treatment in acute injury -Presents with pain, instability, possibly OA TREATMENT (APM):

-UCL reconstruction with free tendon graft -Approach as in acute repair -Scar, redundant UCL resected -2 holes (3-4 mm diameter each) are made with drill/curettes/gouges at the ulnar cortex of the proximal phalangeal base at the 1 & 5 o‘clock positions 3-4 mm distal and parallel to the articular surface. Holes are connected. -A bony tunnel (4-5 mm diameter) is made in the metacarpal at the ulnar concavity of the metacarpal head and extending slightly obliquely dorsoradially out the radial cortex. -Obtain a free tendon graft (palmaris longus, ½ FCR, or toe extensor) -Whip stitch the end of the free tendon grafts and pass through tunnels with suture passer so tendon graft is a ―V‖ with the apex proximal and made from 2 converging tendon ends passing through one tunnel. Graft should be under the sagittal band. -On radial cortex, may fix tendons to adjacent periosteum, or to bone anchor (placed 5-8 mm away), or over button -Test stability so does not open > 10 degrees -may transfix MP joint with K-wire if volarly subluxed preop -Post-op similar to acute situation THUMB RCL INJURY -Similar to UCL, except no Stener lesion -Mechanism: adduction / torsion -RCL torn with equal frequency proximally and distally -Proximal phalanx may shift volarly on radial side, causing a dorsoradial prominence of the metacarpal head and volar subluxing of proximal phalanx on x-ray -Differentiate complete vs. partial tear in same way as UCL TREATMENT: Controversial, but APM: similar to UCL: non-operative of partial, operative for completes. For chronics, try to repair as in acute; free tendon graft if not able DORSAL MCP DISLOCATIONS -Most thumb MP dislocations are dorsal -Mechanism: hyperextension with rupture of volar plate and capsule and part of collateral ligaments -Presents in hyperextension, adduction -Most reducible; if not, interposed volar plate or FPL TREATMENT (APM): -Radial and median nerve wrist block. Flex and adduct metacarpal, IP, and wrist. Direct pressure on base of proximal phalanx to push over metacarpal head (no longitudinal traction, as this may interpose tissue). After reduction, test collateral stability (follow UCL / RCL guidelines above). Check x-ray to confirm congruent reduction. Immobilize 4 weeks in 25 degrees flexion. If closed reduction fails, open through volar or radial midaxial approach. Remove interposed tissue, may need K-wire stabilization at 25 degrees flexion if unstable. CHRONIC VOLAR THUMB MCP INSTABILITY -May occur if untreated / too brief immobilization of dorsal MP dislocation -Present with hyperextension instability, pain, weakness TREATMENT:

-Posner – abductor pollicis and FPB advanced 1.5 cm distally along radiovolar surface and fixed with pullout suture -Eaton – Volar capsulodesis: volar plate advanced proximally into decorticated retrocondylar fossa and suture secured by volar to dorsal bone tunnels; joint held with K-wire (0.045-inch) x 4 weeks. THUMB CMC ANATOMY -CMC joint is biconcave saddle, with little stability from bony architecture -Main stabilization is from 4 thickenings (=ligaments) in joint capsule: (1) volar anterior oblique ligament – most important. Passes from trapezium to volar beak of thumb metacarpal and resists dorsal subluxation during pinch. (2) dorsal oblique (posterior oblique), (3) dorsoradial, (4) intermetacarpal -CMC has motion in 3 planes: flexion-extension, abduction-adduction, pronation-supination THUMB CMC DISLOCATIONS -Rare -Dorsal; mechanism: axial compression on flexed thumb -X-rays: wide joint space or slight dorsoradial shift. Check stress views against contralateral view. Stress views: bilateral thumb PA view with distal phalanges pressing together along their radial borders to lever out base of metacarpals in radial direction TREATMENT (APM) -Partial volar ligament tear: if acute post-traumatic pain in thumb CMC joint, but no clinical instability or radiographic subluxation. Treatment: thumb spica cast (abduction-extension) x 4 weeks. -Complete dislocation / volar ligament tear: clinically unstable / radiographic subluxation. Treatment: closed reduction – hold metacarpal in abduction / extension and apply direct pressure to dorsoradial aspect of metacarpal base. Thumb spica cast. If cast does not hold reduction, then percutaneous K-wire indicated. If still cannot achieve reduction, interposed tissue exists and open reduction and volar ligament reconstruction must be performed. TECHNIQUE FOR VOLAR LIGAMENT RECONSTRUCTION OF THUMB CMC JOINT -Expose CMC radio-volarly along border of glaborous skin (modified Wagner volar approach). Avoid injury to palmar cutaneous median nerve, superficial radial artery, and dorsal sensory radial nerve. Elevate thenar muscles extracapsular/periosteally. Incise volar / radial capsule and remove interposed tissue. -Identify FCR at wrist crease and unroof distally to midportion of trapezium. Harvest radial ½ of FCR, detaching it 8 cm proximal to the wrist, but leaving it attached distally. Harvest using series of short transverse incision, or loop of 0-prolene to split at proximally made crotch. Whip stitch end of graft. -Create a bony tunnel at base of metacarpal perpendicular to thumbnail emerging just distal to metacarpal volar beak. Pass graft from volar to dorsal with suture passer, reduce the joint and suture the graft at the dorsal periosteum. Pass under the APL and suture to periosteum to

reinforce dorsal capsule. Loop around intact FCR and tie back up to volar capsule. Avoid excessive tension. -Transfix MP at 20 degrees. Reattach thenar muscles. Thumb spica splint/cast. D/C cast and Kwires at 4 weeks. Chapter 27 – Carpal bone fractures (Peter Amadio, Julio Taleisnik) LATSC=long arm thumb spica cast. SATSC=short arm thumb spica cast. SCAPHOID FRACTURES: -Most common carpal fracture (79%), followed by triquetrum (14%); others each 2 or less % each -2nd wrist fracture only to distal radius fracture -Usually FOOSH in young adult male, usually middle third (waist) fracture MECHANISM: -Wrist extended >90 degrees, load on radial half of palm SCAPHOID BLOOD SUPPLY: -Dorsal branch and palmar branch, both from radial artery. Palmar branch enters and is limited to distal pole. Dorsal branch enters distally and has variable proximal extension. 20% with single small foramen proximal to waist (Obletz JBJS 1938). Negligible blood supply from ligaments to proximal pole (RSL or SL). Therefore 30% AVN with proximal pole fractures and healing is 2 more months than middle third fractures. DIAGNOSIS: -Snuff box / volar scaphoid tenderness, x-rays (4 views: PA fist ulnar deviated,lateral, 2 obliques). If x-rays negative, APM: SATSC, repeat exam and x-ray OOP in 2 weeks; bone scan if inconclusive. CT helpful to evaluate displacement. R/O ligamentous injury. CLASSIFICATION: -Acute vs chronic, nondisplaced vs displaced, location, geometry FIXATION TECHNIQUES: -K-wires, especially if AVN of proximal fragment. -Cannulated Herbert-Whipple screw, inserted with jig from volar approach, distal to proximal ACUTE SCAPHOID FRACTURE (MIDDLE THIRD) MANAGEMENT APM: -Fresh stable, undisplaced: SATSC -Fresh undisplaced but potentially unstable (verticle oblique or reduced trans-scaphoid dislocations) and previously untreated stable fractures older than 3 weeks: LATSC -Fresh displaced or angulated: ORIF (K-wires or Herbert screw) -Nonunions, asymptomatic, stable: Recommend PEMF or Russe graft because strong likelihood of late OA -Symptomatic nonunions without OA, AVN, or carpal collapse: PEMF if stable, undisplaced < 5 years old; Russe bone graft if displaced or bone resorption and nonunion > 5 years old -Nonunions with carpal collapse (DISI) without OA or AVN: Anterior wedge bone graft with internal fixation (K-wire or Herbert screw)

-Nonunion with limited radioscaphoid OA without AVN: bone graft and limited styloidectomy, or scaphoid excision and midcarpal arthrodesis, particularly if carpal alignment is suggestive of midcarpal (lunocapitate) instability or collapse -Nonunion with definite AVN: Vascularized bone graft or replacement of proximal fragment with soft tissue, or scaphoid excision and midcarpal arthrodesis -Nonunion with more extensive OA: Excision of scaphoid with midcarpal arthrodesis or total wrist arthrodesis

PROXIMAL POLE (THIRD) SCAPHOID FRACTURE AND NONUNION: APM: -Fresh, full third fracture: Retrograde fixation from dorsal approach with Herbert screw or Kwires. If surgery cannot be performed, rejected by patient, fragment not amenable: LATSC, followed by SATSC; consider 3 finger cast -Delayed or nonunion, full third fragment: Vascularized bone graft; or PEMF with LATSC followed by SATSC -Persistent nonunion, full third, no AVN: Matti or Russe bone graft and internal fixation, with Kwire fixation to lunate -Nonunion after failed RX or with AVN and very small proximal pole fracture: Excision of fragment with soft tissue interposition DISTAL THIRD SCAPHOID FRACTURE: APM: -Tuberosity fracture: SATSC -Distal third Fracture: SATSC -Intra-articular displaced: ORIF -Nonunion: very rare, amenable to Russe bone graft SURGICAL TECHNIQUE - SCAPHOID ORIF THROUGH DORSAL APPROACH -Approach through 3rd dorsal compartment. Capsule incised from 5mm ulnar to Lister‘s, curving outward over midcarpal joint. Capsule detached from dorsal and lateral edge of scaphoid, allowing RS and SC joint visualization. Wrist flexed by assistant and anatomic reduction done under direct vision, usually with 2 K-wires as joysticks. Once reduced, 1 x 0.045-inch K-wire inserted from proximal pole, following long axis of bone. Check with fluoro and if good, follow with another non-parallel K-wire, Herbert screw (freehand), or cannulated Whipple-Herbert screw using the preinserted wire. Check RL and LC alignment and check with fluoro. Re-do if articular incongruency, scaphoid deformity, DISI. May need to bone graft if comminuted. May need additional volar exposure and trapezoidal graft if scaphoid with persistent flexion deformity. Close capsule, SATSC with IP free. If only K-wires used, remove wires at 8 weeks and new SATSC until healed. If compression screw used with strong fixation, may d/c cast at 4-6 weeks and start ROM. Grip-strengthening not started until 12 weeks, heavy use not allowed for 6-12 months.

SCAPHOID NONUNION -Usually treated with surgery

-Few nonunions remain stable or undisplaced or free of OA after 10 years. Even asymptomatic patients with stable undisplaced non-unions should be advised of possible late OA. NONOPERATIVE RX: -For stable, undisplaced nonunion, prolonged immobilization produces high % union. Electrical stimulation is additional alternative to surgery. Still, nonunion usually treated with surgery -PEMF=pulsed electromagnetic field. Mechanism of action not fully understood. Can be invasive, semi, or non-invasive. Probably not as effective as Russe bone graft, but still effective enough to use in some cases (infection, proximal third with AVN). Vascularized bone graft may limit future role of PEMF. OPERATIVE RX: -No arthritis, AVN, cysts, collapse: Russe graft or PEMF -Collapse, no arthritis, no AVN: Fisk-Fernandez graft; if large cysts present, consider Maltese cross graft. If adequate bone graft procedure already done, consider vascularized bone graft. -Any arthritis: Scaphoid excison/midcarpal fusion

-AVN, with or without cysts, collapse: Vascularized bone graft SCAPHOID MALUNION: -―humpback‖ scaphoid = measure humpback portion (dorsally) and internal scaphoid angle (normal = 24 degrees) -results in altered carpal mechanics and pain, weakness, limited motion (especially extension), OA -If intrascaphoid angle is increased by 20 degrees or less (vs contralateral side), then long-term results similar to anatomic union, and no RX needed -Otherwise, Fisk/Fernandez wedge graft if no OA. -If OA, consider salvage procedures BONE GRAFT TECHNIQUE (ORIGINAL RUSSE METHOD) -INDICATIONS: symptomatic non or delayed union without OA, but with satisfactory carpal alignment. Okay if cysts present. -CONTRAINDICATIONS: True AVN of proximal fragment. X-ray not good predictor of AVN. Either need to see lack of punctate bleeding intra-op (Green JHS 1985) or MRI (Trumble JHS 1990). OA. Carpal malalignment. -GRAFT: Either ICBG or distal radius--ICBG with higher union rate:73 vs 47% (Hull Clin Orthop 1976). Most recent Russe modification: 2 corticocancellous grafts with cancellous sides facing each other and 2-mm cancellous chips filling remaining cavity. -RESULTS: Long-term (3-10 year) results good, but post-traumatic OA in 50% -TECHNIQUE RUSSE BONE GRAFT: -5 cm incision, proximal half on radial border FCR, centered at radial styloid tip (which corresponds with level of fracture), distally along border of glaborous skin. Radial artery identified and thenar branch ligated, and main vessel retracted radialward. FCR tendon sheath opened and tendon retracted ulnarward. Elevate thenar muscles. Wrist capsule opened in zigzag:

Proximal leg starts ulnarly and courses radially and parallel 3mm from the volar radius lip. The second part follows the virtual space between the RC and RS ligaments, and the third part detaches the capsule from the trapezium (leaving a cuff). Alternatively, the capsule is divided longitudinally and underlying deep volar radiocarpal ligaments divided partially. Egg-shaped cavity created well into both fracture fragments without power tools. 2 corticocancellous bone grafts obtained from ipsilateral iliac crest and with cancellous surfaces facing each other, ovoid plug fashioned to fit snugly into scaphoid cavity. Graft actually jammed into both fragments as these are forcibly distracted. Once graft is in place, both fragments and graft manually impacted. Internal fixation of 2 parallel longitudinal K-wires used only if instability persists. Repair ligaments/capsule, LATSC x 6 weeks, then SATSC x 6 weeks (if internally fixed or very stable, may use SATSC initially). Union rates > 90%. VOLAR WEDGE BONE GRAFT TECHNIQUE (FISK-FERNANDEZ) -INDICATIONS: Carpal collapse where scaphoid needs realignment. -TECHNIQUE: Preoperative tracings of injured and normal scaphoid made. Amount of resection and size/shape of bone graft calculated. Volar Russe approach made with distal extension to expose distal pole and medial extension to visualize extended lunate. Resect/freshen surfaces with saw/ronguer. Multiple drill holes in proximal fragment with 0.035 K-wire. Extend and ulnarly deviate wrist, distract scaphoid fragments to correct flexion and length while assistant derotates lunate (with proximal scaphoid fragment) with 0.045 K-wire joystick. With wrist neutral, K-wire inserted in lunate perpendicular to long axis of forearm, just distal to Lister‘s. Correction of DISI then done by rotating K-wire the same amount as the preop RL angle. Another K-wire placed perpendicular to long axis of forearm to hold lunate while first wire driven into radius. All these maneuvers should open scaphoid gap. Trapezoidal corticocancellous bone graft from iliac crest. Graft placed with cortex palmar, 2 0.045 K-wires placed from palmar distal to dorsal proximal, or Herbert screw. Trim excess. If unable to close capsule, use FCR sheath to cover defect. Fluoro to check graft, hardware, carpal angles. If still with DISI, either K-wire lunate in reduced postion to radius x 6 weeks and/or add Blatt capsulodesis. If K-wired, SATSC x 8 weeks, then removable splint until healed (usually 10-11 weeks), K-wires out then. If Herbert screw, mobilize at 2 weeks if stable. VASCULARIZED BONE GRAFTING OF SCAPHOID NONUNION (also see Ch 37) -pronator pedicle graft; Zaidemberg 1,2 intercompartmental graft (Zaidemberg JHS 1991)(Sheetz JHS 1995) TECHNIQUE OF PRONATOR PEDICLE GRAFT -Exposure as in Russe, extend proximally to expose pronator quadratus. Block of radius (1520mm long, 8-10 mm wide, 5-6 mm deep) elevate at level of distal pronator quadratus insertion with fine osteotome. Keep 15-20mm of pronator muscle with it; bluntly dissect pedicle free to rotate on ulnar attachment. If graft does not reach easily, make separate incision over ulna and pronator freed subperiosteally to advance. Graft inserted into scaphoid defect and fixed with 2 longitudinal K-wires. REVISION OF FAILED BONE GRAFT (VBG= vascularized bone graft)

-10-30% scaphoid bone grafts fail to unite. CT helpful in preop. -RX: If CL OA, then salvage procedure. If OA only at radial styloid, VBG and radial styloidectomy. If large cysts in scaphoid, excise cysts with curette and VBG or Maltese cross graft. If AVN, then VBG. If neither cysts nor avascularity and carpal malalignment and/or humpback deformity, then Fisk-Fernandez wedge graft. SALVAGE AND PALLIATIVE PROCEDURES RADIAL STYLOIDECTOMY: -Used if scaphoid-styloid arthrosis, and combined with bone graft. Not done alone. -TECHNIQUE: Subperiosteal dissection through anatomic snuff-box. Preserve volar radial ligament attachments. If more than 1 cm styloid removed, the RSC origin will be damaged, leading to carpal instability. PROXIMAL ROW CARPECTOMY: - Preferable to fusion where motion is preferred - Contraindicated if radiocarpal arthrosis -PRC vs intercarpal fusion: similar pain relief and strength, but PRC 71 degree motion, fusion 54 degrees (Krakauer JHS 1994) -PRC TECHNIQUE: Longitudinal incision, open 3rd compartment, subperiosteal dissection of 2nd and 4th compartments, entire lunate and triquetrum removed, scaphoid excised (entirely or leave distal third and perform styloidectomy), pisiform left. Proximal pole capitate seated in lunate fossa of radius; K-wire 4 weeks if unstable. Excise terminal posterior interosseous nerve – lying beneath deep fascial layer, on the interosseous membrane, along the ulnar border of the distal radius. Divided 2-3 cm proximal to articular surface of radius. SAC x 3-5 weeks, then removable splint and ROM 2-4 weeks. PARTIAL ARTHRODESIS: (see Ch 5) -Usually done as salvage procedure, especially if repeated bone graft failure and to prevent midcarpal collapse in unstable wrists. If radioscaphoid and midcarpal arthritis, then SLAC procedure. If radioscaphoid arthritis, but midcarpal intact, then consider radioscapholunate fusion. SCAPHOID FRACTURES IN CHILDREN -Not common. Usually amenable to casting. Carpal malalignment has been shown to resolve with growth (Suzuki JHS 1993) ______________________________________________________________________________ _______ PREISER‘S DISEASE =AVN of scaphoid (either whole bone or proximal pole) -Etiology mainly idiopathic, but possibly related to steroids, repetitive trauma, collagen vascular disease -Symptoms: local pain and tenderness -Radiology: x-rays: sclerosis, fragmentation. MRI: loss of signal. -RX: not standardized. If lack of severe pain and disability, then nonoperative RX (rehab, NSAIDs). Otherwise, joint debridement, electrical stim have been tried, with mixed results. May try vascularized bone graft, but if bone too fragmented, be ready to perform scaphoid excison/midcarpal arthrodesis or PRC.

______________________________________________________________________________ ________ LUNATE ACUTE LUNATE FRACTURES: -Rare -Group 1: Volar pole (most common). Group 2: Small marginal fx. Group 3: Dorsal pole. Group 4: Sagittal. Group 5: Transverse. RX: Displaced Groups 1 & 5: ORIF. Groups 2-4: More likely nonoperative. ______________________________________________________________________________ _______

KIENBOCKS DISEASE ETIOLOGY: -not completely known -Elevated intraosseous pressure from altered carpal mechanics may be most likely common pathway -Statistically significant relationship between negative ulnar variant and Kienbocks -Zapico type I lunate with proximal apex or crest associated with ulnar-minus wrist and Kienbocks. Types II and III are more square and associated with ulnar-neutral and positive wrists and no Kienbocks. DIAGNOSIS: -H & P: pain and stiffness, swelling and tenderness at lunate dorsally. Decreased ROM and grip strength. -Diagnosis usually made by x-rays: sclerosis, loss of height, fragmentation. If early, may only see ulna-minus variant and type I lunate. Later, carpal dissociation with scaphoid palmarflexed and Tq extended, then later OA. MRI: Signal change on radial side. Must differentiate from ulnar impaction (ulna-positive and changes on ulnar side) BONE SCAN: increased uptake early. CLINICAL STAGING (Lichtman): -Stage 0: MRI or bone scan abnormal but x-rays negative -Stage I: Linear or compression fracture, but normal density and architecture -Stage II: Density abnormal, no lunate or carpal collapse -Stage IIIA: Lunate collapse, no carpal collapse -Stage IIIB: Lunate collapse and carpal collapse -Stage IV: extensive OA TREATMENT:

-Consider 4 topics: 1) stage 2) ulnar variance 3) patient‘s age and functional level 4) OA presence -No universally accepted treatment plan NONOPERATIVE RX: -Associated with radiographic progression, but this is weakly associated with symptoms. -Pain may not increase with nonoperative RX, but it is unlikely to decrease. Therefore, if significant symptoms, operative RX may decrease symptoms. OPERATIVE RX: (APM)-(unload lunate) -Stages I-III, ulna-minus or neutral, skeletally mature: radial shortening -Stages I-III, ulna-positive, skeletally mature: STT fusion or capitate shortening (Other view: Garcia-Elias (Ch. 28) for Stage IIIB: SC arthrodesis, debridement of lunate-unstable fragments, 5-10 degree lateral closing wedge osteotomy with or without radial shortening depending on ulnar variance) -Stage IV: PRC or wrist fusion -TECHNIQUE OF RADIAL SHORTENING: -Longitudinal radiopalmar approach, ulnar to radial artery. Pronator quadratus and FPL exposed, perisoteum incised along insertion, and radius exposed subperiosteally. Osteotomy performed and wafer of radius removed (at least 2mm) to make ulnar neutral. Wafer morselized and used as graft. Fix with T compression plate, or make osteotomy proximal and use straight DCP. Make sure no gap and no block to rotation (may need radial translation of distal radius). Some use dorsal approach (easier approach and PINectomy can be performed), but often will need HWR because of prominence & tendon irritation. LAC x 4 weeks, SAC x 4 weeks. -Other RX: ulnar lengthening, vascularized bone graft KIENBOCKS IN CHILDREN: -Rare -If under 12 y.o., then cast 6-12 weeks -If over 12, try casting, but will probably respond more like adults. ______________________________________________________________________________ ________ TRIQUETRUM FRACTURES -2nd most common carpal fracture -2 types: dorsal cortical (from avulsion, shear, or impaction), and body -RX: Dorsal cortical: 6 weeks SAC. Excise fragment later if tender. Body: 6 weeks SAC PISIFORM FRACTURES -Uncommon -MECHANISM: direct blow or repetitive trauma -RADIOGRAPHS: supination oblique and carpal tunnel views, CT RX: Cast. If symptomatic nonunion or pisotriquetral OA, then excise (little effect on strength)

PISIFORM EXCISION TECHNIQUE: -Volar zigzag incision made radial to pisiform. Expose ulnar nerve and divide pisohamate ligament to decompress Guyon‘s canal. If fracture old and FCU intact, split FCU longitudinally and shell out pisiform. Repair and allow motion. If transverse fracture with diastasis and FCU not intact, then shell out, repair, and immobilize wrist in slight flexion and ulnar deviation x 4 weeks. TRAPEZIUM FRACTURES -Infrequent -Usually associated with 1st metacarpal and distal radius fractures -3 main types: body, marginal trapeziometacarpal, trapezial ridge -Occasionally with median nerve symptoms -X-rays:carpal tunnel view, Bett‘s view: elbow raised, thumb extended and abducted, some pronation -RX: Undisplaced body and marginal trapeziometacarpal fractures: SATSC x 4 weeks. --Displaced body fractures: ORIF with screws or K-wires --Trapezial ridge: Type I (base): May heal with SATSC. Type II (tip): SATSC, but less likely to heal. If nonunion and symptomatic, then excise through palmar approach. -TRAPEZIAL DISLOCATION: RX: CR attempted. If unsuccessful, then ORIF with K-wires x 4weeks. -POST-TRAUMATIC OA: RX: LRTI or arthrodesis TRAPEZOID FRACTURES -Rare -Isolated without displacement: nonoperative RX -If displaced, may need CR vs ORIF. -If chronic injury, open reduction, bone graft, CMC arthrodesis CAPITATE FRACTURES -May occur alone or in combination with other carpal fractures. May need CT to further evaluate. Isolated fractures often nondisplaced, but waist fractures often result in AVN and/or nonunion which may need midcarpal arthrodesis, bone grafting, or excision arthroplasty. SCAPHOCAPITATE SYNDROME =Capitate neck fracture with rotation of proximal fragment in association with scaphoid waist fracture. -MECHANISM: FOOSH, or direct blow to wrist dorsum in volar flexion -RX: If within 3-4 weeks, ORIF both through dorsal approach. If late and scaphoid healing satisfactorily, observe. If significant symptoms and malalignment of both or capitate AVN, then salvage with midcarpal arthrodesis or capitate head resection arthroplasty. HAMATE FRACTURES

-Either body or hook -H & P: Pain, tenderness at ulnar wrist, swell BODY: -May need oblique x-rays or CT to detect -RX: Isolated nondisplaced body fracture: Ulnar gutter case x 4 weeks. If displaced or CMC fracture/dislocation, then CRIF vs ORIF with K-wires or mini-screws. HOOK: -H & P: Deep, ulnar wrist pain in golfers, tennis, baseball, squash players. Tender over hook, resisted flexion of 5th digit reproduces pain. May have ulnar nerve symptoms from hemorrhage. May rupture flexor tendons over fracture fragments. -Radiographs: Carpal tunnel view or CT scan -Most untreated hook fractures( nonunion. 30%( AVN. Poor blood supply, most from base of hook. -RX: If acute, ulnar gutter cast x 4 weeks. If late and symptomatic, excise fragments-some pain and weakness persists, but most return to full activity. Some report bone grafting (not APM) -TECHNIQUE OF HOOK EXCISION: -Approach hook through short palmar incision. Protect ulnar nerve motor branch. Subperiosteal dissection to excise fragment(s). Base rasped smooth and covered with periosteum. Splint x 2 weeks. CHAPTER 28 – CARPAL INSTABILITIES AND DISLOCATIONS (Marc Garcia-Elias) LIGAMENTOUS ANATOMY -Carpal ligaments are intracapsular, except for transverse carpal ligament and pisihamatum ligament and pisimetacarpicum ligament (to base of 5th metacarpal) -Carpal ligaments do not have distinct edges and there are numerous anatomic variations, leading to different descriptions in the literature -Extrinsic ligaments=connect forearm bones with carpus -Intrinsic ligaments=have origins and insertions within carpus -Extrinsic ligaments are stiffer but with lower ultimate yield than intrinsic ligaments (Johnston RB, JHS, 1995) - Extrinsic ligaments tend to suffer mid-substance ruptures, and intrinsic ligaments more frequently avulse off of bone (Linscheid, Hand Clin, 1992) EXTRINSIC CARPAL LIGAMENTS -Superficial Extrinsic Radiocarpal Ligaments: PALMAR: RS, LRL, RC (courses around palmar concavity of scaphoid, forming fulcrum over which scaphoid rotates). RC and LRL diverge distally, with space between called: interligamentous sulcus (Berger JHS ‘90 & ‘91). DORSAL: Dorsal RTq ligament. -Superficial Extrinsic Ulnocarpal Ligaments: UC -ulnocapitate (from palmar edge of TFC to capitate neck. RC & UC converge on capitate to form ―V‖. SPACE OF POIRIER=triangular

space between ―v‖ and distal edge of LRL; a weak zone through which perilunate dislocations frequently occur (Mayfield, Clin Orthop, ‘84) -Deep Extrinsic Radiocarpal Ligaments: SRL (short radiolunate)-originates ulnar to LRL from radius; stabilizes lunate from dorsal dislocation in hyperextension injury. RSL-may not be a true ligament, but rather a neurovascular bundle. -Deep Extrinsic Ulnocarpal Ligaments: UTq and UL-from palmar edge of TFC. These, with ulnocapitate ligament form the ulnocarpal ligamentous complex. INTRINSIC CARPAL LIGAMENTS -Scapholunate interosseous (SLIO) ligaments: formed by 3 distinct structures: 2 SL ligaments (palmar and dorsal) and the proximal fibrocartilaginous membrane. Dorsal ligament plays a key role in stability, palmar ligament plays minor role. -Lunotriquetral interosseous ligaments: Has 3 parts like SLIO. -Dorsal intercarpal ligament: From Tq, fans out to insert on scaphoid, trapezium, and trapezoid. -Palmar intercarpal ligaments: TQHC, SC, STT BIOMECHANICS KINEMATICS = carpal motion DISTAL CARPAL ROW (DCR) -Very little motion between bones in the distal carpal row -In wrist flexion, DCR flexes and ulnarly deviates (opposite in extension) -In wrist radial deviation, DCR radially deviates, extends, and supinates (opposite in ulnar deviation) PROXIMAL CARPAL ROW (PCR) -Less tightly bound than DCR; they move in similar directions, but not as much as DCR -Average SL angle in full wrist flexion is 76 degrees; 35 degrees in full extension -PCR flex in radial deviation, extend in ulnar deviation CARPAL KINETICS = force transmission across the wrist CARPAL INSTABILTY DEFINITION = not capable of preserving normal kinematic and kinetics which leads to pain and/or loss of function. CLASSIFICATION: 6 features -CHRONICITY: Acute < 1 week (max healing potential), Subacute 1-6 weeks (some healing potential), Chronic > 6 weeks (little primary healing potential) -CONSTANCY: Predynamic, Dynamic, Static Reducible, Static Irreducible -ETIOLOGY: Traumatic (most common), Congenital, Inflammatory, Arthritis, Neoplastic, Iatrogenic -LOCATION: Radiocarpal, Proximal Intercarpal, Midcarpal, Distal Intercarpal, CMC, Specific Bones -DIRECTION: DISI, VISI, Translations (Ulnar, Radial, Palmar, Dorsal, Proximal, Distal) -PATTERN (Mayo): ---Carpal Instability Dissociative (CID): Major derangement (fracture or ligament tear) between bones in the same row ---Carpal Instability Non-dissociative (CIND): Major derangement between different rows

---Carpal Instability Complex (CIC): Combo of CID and CIND ---Carpal instability adaptive (CIA): Extrinsic pathology (proximal or distal) leading to wrist instability (i.e. DRF) PATHOMECHANICS -Either Direct Mechanism (crush, etc.), or Indirect Mechanism (FOOSH) -PERILUNATE INSTABILITY (PLI): STAGE I - SL dissociation / Scaphoid Fracture. STAGE II – Lunocapitate Dislocation. Distal row translates dorsally. STAGE III – Lunotriquetral Disruption / Triquetrum Fracture. STAGE IV – Lunate Dislocation. Capitate forces palmar lunate extrusion. -Possible that ―Reversed PLI‖ exists as well: Stages from ulnar to radial. DIAGNOSIS -History may be one of violent injury or patient may not recall event PHYSICAL EXAM -direct palpation, ROM, grip strength

RADIOLOGY -Xray: PA, lateral, scaphoid (PA in ulnar deviation), 45-degree semipronated (from lateral) oblique. Other views: AP (palm up) clenched fist may accentuate SL dissociation. Dynamic views of PA maximum radial / ulnar deviation and lateral maximum flexion / extension—look for differences in angles. Gilula‘s 3 lines (outline proximal and distal borders of proximal row, and proximal border of distal row)-stepoff indicates derangement. Overlap or >4mm gap between carpal bones indicate derangement. -Carpal Bone Alignment: ---SL ANGLE: normal from 30-60 degrees. >80 is definite SL dissociation ---CL ANGLE: normal 0 +/-15 degrees ---RL ANGLE: normal 0 degrees. DISI if > 15. ---ULNAR VARIANCE: take with shoulder 90, elbow 90 degrees, wrist neutral. ---CARPAL HEIGHT RATIO: carpal height (from base 3rd MC to radius) / 3rd MC length=0.54 (nl). Carpal height / capitate length=1.57 (nl). ---ULNAR TRANSLATION RATIO: Chamay method: perpendicular distance form center of capitate to radial styloid / 3rd MC length=0.28 (nl). -CT: 2mm intervals. Ideal to assess scaphoid fracture-non/malunion. Also evaluate fusion. -DISTRACTION VIEWS: If fracture/dislocation, may hang in finger traps to get better view. -STRESS VIEWS: Dorsal( palmar (& vice versa) stress lateral views. -CINERADIOGRAPHS: 35-mm (used by cardiologists). Gives permanent record and better detail (than fluoro). R & U deviation (RUD) in AP & PA. RUD and F/E in lateral view. -3-D CT: May help for scaphoid malunion or complex carpal dislocation.

-ARTHROGRAPHY: Degenerative perforations increase with age. 74% with abnormal findings in opposite, asymptomatic wrist (Herbert JHS 1990). -BONE SCAN: Get if suspect obscure intraosseous abnormality) infection, tumor, osteochondral fracture) -MRI: Seldom used to evaluate instability. May be useful if suspect extraarticular disease, AVN. -ARTHROSCOPY: Many consider it the gold standard for the diagnosis of occult ligamentous injuries of the wrist. ______________________________________________________________________________ _______ CARPAL INSTABILITY DISSOCIATIVE (CID) -Proximal CID common (SL & LTq dissociation, scaphoid fracture, Kienbocks) -Distal CID rare, usually form axial carpal dislocation SCAPHOLUNATE DISSOCIATION (SLD) PATHOMECHANICS -Usually occurs from hyperextension wrist (with ulnar deviation and midcarpal supination) - Predynamic Instability: If only palmar and proximal portions of SLIL sectioned, only minor kinematic alterations created. - Dynamic Instability: If all 3 parts of SLIL sectioned, scaphoid becomes proximally unconstrained and RS motion increases, as if belonged to the distal row. RL motion decreases. Static Instability has not been demonstrated with SLIL sectioning alone. - Static Instability = Rotatory Subluxation of Scaphoid (RSS). If both proximal (SLIL) and distal (STT ligament) injured. Distal ligaments either tear acutely or progressively stretch after proximal injury. Scaphoid flexes, ulnar deviates, pronates. Lunate opposite. Unknown why they reach these positions. This leads to abnormal compressive and shear stresses at the RS fossa leading to OA (Watson‘s spoon analogy). The RL fossa is round, so this does not occur. DIAGNOSIS: -Frequently missed -Suspect if FOOSH, even with other injuries (DRF, scaphoid fracture) (31% DRF with SLDGeissler JBJS 1996) -Wrist trauma most common cause; others: elbow trauma, DWG surgery, RA, congenital, infection -SYMPTOMS: Pain (may be activity related), sometimes with click/snap, limited motion, weak grasp, swell -PHYSICAL EXAM: Point tender over dorsal SL region, most also with snuffbox and palmar scaphoid tuberosity tenderness. WATSON SCAPHOID SHIFT TEST: Thumb placed on distal pole of scaphoid as wrist passively moved from ulnar to radial deviation. Normal scaphoid will not be able to flex (but there may be pain). If SLIL injured, scaphoid will subluxate dorsally with pain. When thumb pressure released, scaphoid reduces with typical click/snap. Compare with opposite side, although sometimes ―asymptomatic‖ wrist with positive findings too. WOLFE TEST (Wolfe JHS 1994): Wrist partially flexed, extend index and middle fingers against resistance results in SL pain.

-RADIOLOGY: Increased SL space (>3mm), Scaphoid Ring Sign (if RSS), SL angle > 60 degrees, Increased angles vs contralateral side with dynamic studies -STAGING: Dynamic, Static, SLAC. Not universally accepted theory=Predynamic (Watson: Positive Watson test, but negative radiographic tests, including dynamic and cine.) GEISSLER ARTHROSCOPIC CLASSIFICATION (Geissler, CORR, 1996) GRADE I: Attenuation or hemorrhage seen (seen from RC joint), no incongruency (from midcarpal space) GRADE II: Incongruency / step-off. Slight gap less than width of 1mm probe. GRADE III: Probe can pass between SL GRADE IV: Scope (2.7mm) can drive through (may immobilize I, reduce and pin II, repair/recon III-IV) TREATMENT (APM): --Acute and subacute dynamic and static (if malalignment correctable and adequate tissue and no OA) ( Open reduction, ligament repair, dorsal capsulodesis. If no good ligament, add Brunelli FCR recon. SURGICAL TECHNIQUE (SLIL REPAIR AND BLATT) (need MicroMitek suture anchors, K-wires, curettes, rongeurs, burr, mini & small fragment sets) 1. 5 cm incision centered over Lister‘s (dorsal, longitudinal) 2. Divide dorsal retinaculum over 3rd compartment, open 3rd compartment, retract EPL radially, 4th compartment tendons ulnarly. Protect dorsal sensory branches 3. Expose joint through straight capsular incision in line with Lister‘s. Elevate ulnar flap off radius to exposed lunate; minimize elevation of radial flap. ―T‖ the radial flap-beyond the distal 1/3 of the scaphoid. 4. Trough made (curette, rongeur, or burr) at SLIL insertion and distal 1/3 scaphoid 5. Place MicroMitek anchors in SL and distal pole scaphoid (check with fluoro) 6. Reduce SL with joysticks (hold with Mersilene). Reduce capitate with palmar force 7. Place 2 x 0.045 inch K-wires divergently from S ( L and 1 from S(C. (Watch for radial artery and nerve. Cut and spread; protect with mini-frag soft tissue protector. Or, push in PC & visualize directly on distal pole scaphoid) 8. Tie SL sutures 9. Pull capsule distally and tie (Blatt capsulodesis), imbricate distal ―T‖ portion; repair dorsal capsule side to side 10. Immobilize in LATSC in pronation x 8 weeks (d/c cast and wires @ 8 weeks), then velcro splint x 4 weeks and start gentle ROM. No resistive palm press (wrist extension) x at least 6 months --If malalignment irreducible, but no OA ( Partial wrist fusion (SLC or SC, Watson likes STT. Controversial which is best) --If SLAC I or II ( RSL fusion and excision distal 1/3 scaphoid. (Controversial. For SLAC I, consider styloidectomy and partial fusion. For SLAC II, consider SLAC procedure) --If SLAC III or IV ( SLAC procedure --If global OA ( Total Wrist Arthrodesis

OTHER TREATMENTS: FOR SUBACUTE, REDUCIBLE SLD WITHOUT OA: CR,PCP: Joystick reduced, then K-wire (2 SL, 1 SC), or RS, RL, SL OTHER CAPSULODESES: -HERBERT (distally based flap to radius) -LINSCHEID (distally based strip of dorsal intercarpal ligament to radius) TENDON RECONSTRUCTIONS: (considered experimental--Long term results unknown) -BRUNELLI: Distally based FCR strip tunneled from palmar to dorsal through scaphoid, then sutured to remnants of SLIL, then suture anchored to dorsal-ulnar radius. -LINSCHEID: 2 transverse incision made-1 short palmar over scaphoid tuberosity, the other wide transverse over wrist dorsum. Distally based ECRB strip passed from dorsal to palmar through 4 mm tunnel in distal pole scaphoid, then wrapped around waist and pulled dorsally. Pass under LTq ligament, pulled taut, and sutured to itself. -ALMQUIST: Distally based ECRB strip passed through capitate, scaphoid, lunate, and out palmarly and tacked to volar radius. BONE-LIGAMENT-BONE GRAFTS: (considered experimental--Long term results unknown) FOR CHRONIC, IRREDUCIBLE SLD WITHOUT OA: STT ARTHRODESIS: -Popular, also known as triscaphoid fusion -Goal is to realign the proximal pole of the scaphoid relative to its fossa. Important that external dimensions

and alignment returned to normal. Watson JHS 1986: recommends scaphoid tilted 50 degrees from forearm, achieved by extending wrist 25 and radially deviating 20 degrees. Kleinman: Fix scaphoid to capitate with 2 K-wires, then remove STT cartilage, fill with bone graft, then insert K-wires across STT. -Watson JHS 1989: performs styloidectomy as routine part of STT fusion (stops impingement) -Nonunion 14% SC ARTHRODESIS SLC ARTHRODESIS SL ARTHRODESIS-least reliable method CHRONIC, IRREDUCIBLE SLD WITH OA -RSL OR RS ARTHRODESIS: For SLAC I or II, may add resection of distal 1/3 scaphoid to improve motion (flexion and radial deviation) -RADIAL STYLOIDECTOMY: Combined with PRC or other salvage procedure -SLAC PROCEDURE: For SLAC III or IV. RL joint must be intact.

-PRC: ―is a controversial salvage operation.‖ Need intact proximal pole capitate and lunate fossa (possibly only for SLAC I or II). Compared to SLAC procedure, avoids long immobilization and risk of nonunion. -TOTAL WRIST ARTHROPLASTY: reasonable in low demand patient, like RA. Not for young, active patients. -TOTAL WRIST ARTHRODESIS: Used if fail other salvage procedures. In heavy laborer with SLAC III or IV, may be the primary procedure of choice. Total pain relief 85%, 65% return to former occupation (Hastings JHS 1984) _______________________________________________________________________ LUNOTRIQUETRAL DISSOCIATION (LTqD) PATHOMECHANICS -Most isolated LTq D are reverse PLI (otherwise stage III PLI) -Horii JHS 1991: sectioning studies: If palmar and dorsal LTq ligaments sectioned, then dynamic instability. If also sectioned RTq ligaments, then SL complex flexed (VISI) and Tq migrates proximally, especially in ulnar deviation. -Late: Midcarpal (LC, LH) OA, not RC OA DIAGNOSIS: HISTORY: -Ulnar sided wrist pain, sometimes with painful click/clunk when ulnar deviate/supinate. -May c/o weakness/instability. -May or may not have h/o trauma: FOOSH in radial deviation with intercarpal pronation (although not proven in lab). If no trauma, may be from ulnar-positive wear of LTq ligament. EXAM: -Point tender over joint (distal and slightly ulnar to DRUJ) -REAGAN BALLOTTEMENT TEST: Hold lunate with index and thumb of one hand and shuck Tq/pisiform with index and thumb of other hand. Positive if pain, crepitus, excess displaceability. -KLEINMAN SHEAR TEST: Stabilize dorsal lunate with thumb just beyond medial edge of distal radius and load pisiform with other thumb in dorsal direction. Positive if pain, crepitus, excess displaceability. DDX: LTq congenital coalition, Avulsion fracture of Tq, OA of hamate proximal pole from midcarpal instability or TqH impingement, PisoTq OA, TFCC tear, Ulnar abutment, ECU tenosynovitis, Dorsal branch ulnar nerve entrapment RADIOLOGY: -XRAYS: ACUTE DYNAMIC INSTABILITY: Standard series is normal. Dynamic series may show S & L linked, but as a unit dissociated from Tq. CHRONIC DYNAMIC INSTABILITY: May have LTq narrowing and cysts. STATIC INSTABILITY (intrinsic and extrinsic ligaments injured) : 1) Break in Gilula‘s line (Tq proximal), 2) LTq gap (rare), 3) VISI 4) LTq angle decreased (normal is +14 degrees) 5) Lunate is moonlike on PA view, 6) SL may have gap and scaphoid may have ring sign

-BONE SCAN: May show increased uptake -ARTHROGRAPHY: May show communication (in asymptomatic wrists too) -CINERADIOGRAPHY: May be helpful -ARTHROSCOPY Increasingly important STAGING (Viegas JHS 1990) -STAGE I: Partial or complete disruption of LTq ligament, without clinical or radiographic dynamic or static VISI. -STAGE II: Complete disruption of LTq ligament, with clinical and/or radiographic dynamic VISI. -STAGE III: Complete disruption of LTq ligament, plus dorsal radiocarpal ligament injury, with clinical and/or radiographic static VISI. TREATMENT (APM):

-ACUTE STAGE I: Short arm cast -CHRONIC STAGE I: Short-term immobilization, NSAIDs, corticosteroid injection. If fails, consider arthroscopic debridement of unstable ligament fragments and multiple K-wires (Osterman, Hand Clin, 1995) -ACUTE COMPLETE TEAR (usually from perilunate dislocation, Stage II): Ligament repair (only if < 1 week old), K-wires -CHRONIC STAGE II: Arthroscopy to confirm. If no TFCC tear or ulnocarpal impaction, then LTq arthrodesis, autogenous bone graft from distal radius, multiple K-wires, SAC x 6 weeks (described by Kirschenbaum JHS 1993). If there is TFCC central perforation from ulnar impaction, then add ulnar shortening if no DRUJ OA or Sauve-Kapandji if DRUJ OA. -STATIC VISI (Stage III): combined radiolunate and LTq arthrodesis ______________________________________________________________________________ ______ CARPAL INSTABILITY SECONDARY TO SCAPHOID DISORDERS -If unstable scaphoid fracture, non/malunion, CID occurs. Distal row follows distal pole and proximal row follows proximal pole. (see Chapter 27 for treatment) CARPAL INSTABILITY IN KIENBOCK‘S -When Stage IIIB (carpal collapse), then CID. VISI, DISI, or direct proximal capitate migration depending on what part of lunate is collapsed the most. (see Chapter 27 for treatment) ______________________________________________________________________________ ________

CARPAL INSTABILITY NON-DISSOCIATIVE (CIND) -Includes radiocarpal CIND and midcarpal CIND RADIOCARPAL CIND: (Includes Ulnar Translocation and Pure RC Dislocation) -From rupture of RC ligaments -Most commonly in RA, Madelung‘s, excessive excision of distal ulna, rarely after RC dislocation ULNAR TRANSLOCATION: -Failure of all radiocarpal ligaments and entire carpus slides ulnarly. RX: RL fusion. (Disappointing results with ligament repairs) PURE RADIOCARPAL DISLOCATION: -Very rare ______________________________________________________________________________ _______ MIDCARPAL CIND (MCI = midcarpal instability) DIAGNOSIS: HX: Painful clunking of wrist with activity, especially with ulnar deviation and pronation. Usually no h/o trauma (except for extrinsic MCI). Usually repetitive stress, congenital laxity. EXAM: Volar sag of midcarpal joint. Most have ―catch-up clunk‖. ROM and grip strength decreased. RADIOLOGY: VISI (except for dorsal MCI). Dorsopalmar stress views demonstrate the type of MCI. CINERADIOGRAPHY: Key tool. Ulnar deviate the wrist and proximal carpal row remains flexed for longer time and then suddenly snaps/clunks into an extended position. CLASSIFICATION (Lichtman JHS 1993): PALMAR MCI: Distal row is palmar to proximal row. Proximal row is flexed (VISI) DORSAL MCI: Normal alignment on standard x-rays, but abnormal dorsal midcarpal subluxation when a dorsally directed force applied. Distal row is dorsal to proximal row. DORSAL AND PALMAR MCI: Both midcarpal and radiocarpal joints are abnormally subluxable in a palmar and dorsal direction, usually the consequence of increased global laxity. EXTRINSIC MCI: MCI from extracarpal problem, usually malunited DRF. TREATMENT (APM): -Most respond to nonoperative treatment: Activity modification avoiding activities that produce painful snapping. Rehab (muscle strengthening). -PALMAR MCI: If fails nonoperative, then Tq-H fusion or ECRB tenodesis. --ECRB TENODESIS SURGICAL TECHNIQUE: 2 longitudinal incisions (dorsal and palmar) are made. 2 x 4mm drill holes are made, one from dorsal capitate palmarly into carpal canal, other from volar Tq to dorsal ridge. Pass tendon through capitate, retrieve palmarly, and pass through Tq. Hold midcarpal joint in ulnar deviation and pin with 2 crossed K-wires. Pull tendon taut and reinforce palmar TqHC ligament with suture. Wrist in neutral and suture tendon to dorsal RTq ligament. SATSC x 8 weeks, the remove wires and change to splint x 1 month. -DORSAL MCI: Surgery seldom required, but if needed, volar approach through carpal tunnel. Radial and ulnar sides of space of Poirier obliterated with 3-0 nonabsorbable sutures to reinforce palmar STq ligament. - DORSAL AND PALMAR MCI: RL fusion. Controversial if surgery

helps. ______________________________________________________________________________ ________ CARPAL INSTABILITY ADAPTIVE (CIA): -Treat extrinsic problem (i.e. Osteotomy for malunited DRF) ______________________________________________________________________________ ________ CARPAL INSTABILTY COMPLEX (CIC) (dorsal/palmar refers to distal carpus in relation to lunate) -Subdivided into 5 groups: Dorsal perilunate dislocations (lesser arc), Dorsal perilunate fracturedislocations (greater arc), Palmar perilunate dislocations, Axial dislocations, Isolated carpal bone dislocations. Dorsal more common. -If xray difficult to interpret, then xray in distraction (finger traps, hang 5-10 lbs) DORSAL PERILUNATE DISLOCATIONS (LESSER ARC INJURIES) TREATMENT (APM): -OPEN REDUCTION, LIGAMENT REPAIR, AND K-WIRE: --SURGICAL TECHNIQUE: Combined dorsal and palmar approaches. Palmar approach through carpal tunnel incision, extending proximally across the wrist in zigzag fashion. Tendons and median nerve retracted radially, revealing consistent transverse rent in palmar capsule, which coincides with the space of Poirier (between RC and LRL ligaments). I&D loose bodies. Reduce lunate by manually pushing it in as assistant applies longitudinal traction. Capsule repaired with 3-0 nonabsorbable sutures. Dorsal approach through 3rd compartment; capsule is usually disrupted. 0) I&D loose bodies 1) Reduce and K-wire RL joint, 2) Reduce, stabilize, and repair dorsal ligaments of LTq, 3) Reduce, stabilize, and repair SL ligaments, 4) Stabilize LC joint with 2 crossed K-wires. If no soft tissue, consider Brunelli or Linscheid tendon reconstruction. If radial styloid fractured, ORIF with K-wires or screw. DORSAL PERILUNATE FRACTURE-DISLOCATIONS (GREATER ARC INJURIES) TRANS-SCAPHOID PERILUNATE DISLOCATIONS; TRANS-SCAPHOID, TRANSCAPITATE PERILUNATE DISLOCATIONS; TRANSTRIQUETRUM DISLOCATIONS: RX as above plus ORIF fractured bone. If present late, still attempt repair/ORIF. If irreducible or OA, then PRC or total wrist arthrodesis. PALMAR PERILUNATE DISLOCATIONS -Either with lunate fracture, or SLD / scaphoid fracture. -RX: ORIF and ligament repairs through palmar and dorsal approaches (see above) AXIAL FRACTURE-DISLOCATIONS OF THE CARPUS -From high-energy dorsopalmar compression (crush) -Usually ½ axial column is stable and other splits (i.e. radial column stable and ulnar column displaces or vice versa)—many permutations -RX: ORIF with K-wires/screws through palmar and dorsal approaches (see above) -Poor prognosis

ISOLATED CARPAL BONE DISLOCATIONS -Rare. These are usually case reports and treated with either ORIF or excision. Except for lunate and scaphoid, excision of an enucleated bone is well tolerated. CHAPTER 29 – DISTAL RADIUS FRACTURES (DRF) - (Diego Fernandez, Andrew Palmer) ANATOMY -Distal radius with 3 concave articular surfaces: scaphoid fossa, lunate fossa, sigmoid notch -Normal radial inclination = 22 degrees. Palmar tilt = 11 degrees. -Radius carries 80% axial load, ulna 20%. Changes in length change load. CLASSIFICATION -Many contemporary authors avoid eponyms and set classifications, but rather describe DRF as open / closed, displaced / nondisplaced, comminuted / noncomminuted, intraarticular / extraarticular, adult / pediatric EPONYMS -COLLES‘ = extraarticular, dorsal angulation, dorsal comminution -BARTON‘s = intraarticular, shear of portion of articular surface; either dorsal or volar -SMITH‘s = extraarticular, volar angulation (=reverse Colles‘) -CHAUFFEUR‘S = styloid fracture -DIE-PUNCH, LUNATE LOAD, MEDIAL CUNEIFORM = intraarticular, dorsal ulnar fragment depressed FRYKMAN, MELONE, AO, MAYO, FERNANDEZ CLASSIFICATIONS

TREATMENT (APM): (STS = sugar tong splint. SAC = short arm cast. LAC = long arm cast. SAS = short arm splint, R = removable) GROUP I (physiologically young and/or active) NON-DISPLACED FRACTURE: STS x 3 weeks, SAC x 3 weeks, R Splint x 3 weeks DISPLACED FRACTURE: CR. UNACCEPTABLE REDUCTION: >2mm radial shortening, articular incongruity, >5 degrees dorsal tilt. If unacceptable, then surgery. GROUP II (physiologically old and/or inactive) NON-DISPLACED FRACTURE: STS x 2 weeks, SAC x 2 weeks, R Splint x 3 weeks DISPLACED FRACTURE: CR. STS x 2 weeks, SAC x 3 weeks, R Splint x 3 weeks. Darrach if with late symptoms. WHY REDUCE? -If malunion, then pain, decreased ROM, subluxation DRUJ, midcarpal instability, posttraumatic OA

-If short 2.5 mm or dorsal tilt, significant increase in ulnar load -If dorsal tilt, then DRUJ incongruent and tight interosseous membrane and limited forearm rotation -If dorsal tilt, then contact area decreased ( OA -If > 2mm articular surface depression, then 90% with symptomatic post-traumatic OA (Knirk & Jupiter, JBJS, 1986) CLOSED REDUCTION TECHNIQUES FINGER TRAPS: -Sterile prep, hematoma block, finger traps (5-10 lbs), CR, fluoro, STS (while in traps. Later, as swelling decreases, can tighten by overwrapping with 4-inch Kling) POSITION: -COLLES‘: slight palmar flexion & ulnar deviation, neutral forearm rotation -SMITH: extension, supination (45-60 degrees) -OTHERS: position opposite of displacement FACTORS THAT SUGGEST UNSTABLE FRACTURE: -initial dorsal angulation > 20 degrees -dorsal metaphyseal comminution -intraarticular disruption -associated ulnar fracture -60 years old / osteoporosis -initial radial shortening METHODS / INDICATIONS OF SKELETAL FIXATION (CR = closed reduction. PP = percutaneous pinning. EF = external fixation. IF = internal fixation. BG = bone graft. OR = open reduction. AR = arthroscopic reduction) CRPP: Unstable extraarticular fractures with good bone quality and without metaphyseal comminution --Kapandji Technique: In finger traps, 0.062 K-wires in fracture, ―lever‖ reduced and advance to other cortex (radial to ulnar, and dorsal to volar) CREF: Unstable extraarticular and intraarticular fractures with metaphyseal comminution (risk of shortening). Also, massive soft tissue swelling, open wounds. --i.e. USE EX-FIX PLACED AT 30 DEGREE OBLIQUE TO LATERAL. NEED TO SEE TRUE LATERAL TO EVALUATE REDUCTION. Use horizontal sterile finger trap traction (5 lbs). CREF + PP: Same as above. PP provide increased stability. --0.062 inch (1.6 mm) K-wires. 2 in radial styloid (1 oblique, 1 subchondral, 1 dorsal to palmar through dorsal-ulnar fragment) CREF + BG: 1. Metaphyseal comminution and bone loss (need to fill gap) 2. Bone graft facilitates reduction of very small fragments that are not reduced by ligamentotaxis and are not amenable to pin fixation. Fragments are elevated back with bone graft.

--Release distraction on ex-fix, 2cm transverse (or longitudinal) incision 1.5 cm proximal to joint. Open retinaculum longitudinally, retract tendons, and elevate fragments with Freer/tamp; fill space with bone graft. CREF + ORIF + BG: For complex fractures that need open reduction. Dorsal, volar, or both approaches. --If mini-open still with inadequate reduction, then open with longitudinal incision, open 3rd compartment, subperiosteally elevate 2nd and 4th compartments. Capsulotomy transversely at RC joint. Reduce fragments (dental pick, Freer), fix with K-wires, bone graft all defects. ARIF: 1. Simple intraarticular fractures with stepoff > 2 mm. 2. Suspicion of concomitant carpal ligamentous injury or DRUJ instability. Contraindications: compartment syndrome or open joint --Optimal time for surgery: 3-7 days. Too early( swelling, compartment syndrome. Too late( hard to move fragments. --Use 0.0625 K-wires as joysticks ORIF: 1. Shearing intraarticular fractures (Barton‘s, reverse Barton‘s, radial styloid) 2. Extraarticular unstable or irreducible fractures with good bone quality 3. Intraarticular fractures as alternative to EF --CONTRAINDICATIONS: elderly, massive osteoporosis(failure of IF, nonunion, RSD. --If more than 4-5 fragment comminution, exact reduction probably not possible. Goal then: improving extra & intra-articular alignment and restoring radial length. --OPEN REDUCTION: ---VOLAR APPROACH (for volar ulnar fragment): Proximal extension of CTR. Retract flexor tendons radially. Interval between flexor tendons and ulnar artery and nerve. Pronator quadratus and volar wrist capsule exposed. Reduce fragment and fix with palmar-dorsal K-wire; retrieved out dorsum and backed up. If larger fragment, small or T buttress plate. VOLAR HENRY APPROACH: between FCR and radial artery. If needed, separate incision for CTR (does not damage palmar branch). ---DORSAL APPROACH (for dorsoulnar fragment): longitudinal incision between 4th and 5th compartments, transverse dorsal capsulotomy. Other interval: through 3rd compartment; subperiosteal dissection of 2nd and 4th compartments. -PLATES: 3.5 mm AO T-plate, Forte plate, AO Pi plate BONE GRAFTING -From iliac crest, olecranon. -Substitutes: bone cement, bone mineral substitutes. -TECHNIQUE ICBG (iliac crest bone graft): Rolled towel under ipsilateral buttock. 5 cm incision beginning 2cm posterior to ASIS. Section of crest 3 cm by 1 cm reflected on medial periosteum with osteotome. Cancellous bone harvested and flap returned. Protect lateral femoral cutaneous nerve: exits medial to ASIS over, behind, or through sartorius 2.5 cm inferior to ASIS.

ASSOCIATED INJURIES OPEN FRACTURES: -APM: I & D, RX fracture (cast, EF, K-wires, &/or plate). Close if clean or < 12 hours open. O/w, 2nd look at 48 hours, possible close vs. STSG if clean. MEDIAN NERVE INJURY: -Acute median nerve symptoms common. -APM: CR in ER. Symptoms usually resolve or improve significantly in 24-48 hours. If worsen or show little to no improvement in 24-48 hours, then CTR, and fix fracture. DRUJ INJURY: -Most common cause of disability after DRF is DRUJ -Address: Intraarticular congruity (sigmoid notch, ulnar head), subluxation from inadequate radius reduction, TFC tears, capsular soft tissue injury, ulnar styloid avulsion with DRUJ subluxation despite anatomic radius reduction, ulnar abutment form radial shortening. -3 types DRUJ lesions: 1) type I: Stable, congruous, TFC and ligaments intact. 2) Type II: Unstable, subluxed/dislocated head from TFC/soft tissue tears or avulsion ulnar styloid. 3) Type III: Potentially unstable, intraarticular incongruity. RX: Type I: RX DRF. Type II: Most treated with 6 weeks cast in neutral rotation. If neutral does not reduce, consider 45 degrees supination cast or K-wire fixation just proximal to DRUJ x 6 weeks. Consider ulnar styid ORIF (see Ch 30) or TFC repair. Type III: fix bone CARPAL LIGAMENT INJURY: -30% SL tears, especially with radiocarpal fx-disloc or severely displaced radial styloid fractures -15% LTq tears with DRF, especially with severe radial shortening and DRUJ disruption -Dissociative (SL, LTq) tears require aggressive operative RX: Fix DRF, reduce carpal bones and K-wire, +/- ligament repair. Partial non-dissociative lesions may heal with just DRF RX. COMPLICATIONS -DRF with high complication rate (31% Cooney JBJS 1980) and frequent poor results -Neuropathy, arthrosis, malunion, nonunion, tendon ruptures, RSD, finger stiffness, Volkmann‘s RSD: -Milder variants common -SXMS: pain, finger stiffness, paresthesia RX: Loosen/change cast/dressing, elevation, hand therapy. CTR if CTS. If do not respond, then symapthetic blocks. NONUNION -DR nonunion rare, but usually symptomatic if occurs. RX: Bone graft and rigid IF. -Ulnar styloid nonunions common, but rarely symptomatic. If symptomatic, usually treated with excision, unless large, then ORIF. If DRUJ unstable too, then TFCC reattached to fovea at time of excision or ORIF. MALUNION

-Common -May need extra or intraarticular or combo osteotomies. Surgically fix early (6-8 weeks after fracture) before soft tissue contracture and DRUJ dysfunction. Significant DRUJ OA may have to be addressed. TECHNIQUE: EXTRAARTICULAR RADIAL OSTEOTOMY: -Preop bilateral x-rays; plan cuts, check ulnar variance. Dorsal incision, open 3rd compartment, etc. (If plate, remove Lister‘s. Osteotomy 1 inch proximal to joint—transverse in AP plane, oblique (parallel to joint surface) in sagittal plane. 1st place K-wire in joint along distal radius for reference. Then drive 2 2.5 mm K-wires in distal fragment, parallel to guide wire. Then make osteotomy with saw. Tenotomy vs. Z-lengthen brachioradialis. Open osteotomy by wrist flexion, lamina spreader, &/or K-wire joysticks. ICBG trapezoid placed in defect and hold with K-wires or plate. -Malunited Smith‘s: Volar Henry approach (between FCR and radial artery), same as above (but opposite), plate strongly recommended. -INTRAARTICULAR OSTEOTOMIES: Done as early as possible. Reserve for relatively simple fractures (radial styloid, Barton‘s, die punch). However if extensive cartilage damage (seen on x-ray, or intraop, or scope) then salvage procedure. DRF IN CHILDREN: -Distal radial epiphyseal injuries are most common epiphyseal injury (50% of all) -Usually between 6-10 y.o. -Usually type II RX: Gentle CR, LAC 4-6 weeks; do not perform repeated CR. Accept 50% off. If late growth plate arrest (sometimes seen without fracture in gymnasts, tennis players), then individualize treatment. Options: epiphysiodesis distal ulna, distal radial osteotomy, ulnar shortening, epiphyseal bar resection and insertion fat spacer, or combo.

Chapter 30 - The Distal Radioulnar Joint (William Bowers) (triple choice=Darrach vs. Suave Kapandji, vs HIT) -Anatomy: TFCC=TFC, volar ulnolunate and ulnotriquetral ligaments, ECU sheath, DRUL, VRUL -Special xrays: PA ulnar deviated, fist (squeeze object), comparison forearm for malunion -CT: comparison in neutral, max supination and pronation. MRI. Triple injection arthrographyasymptomatic lesions in SL ligament (36%), LTq (40%), TFC (50%) 1. Fractures A. Sigmoid notch- Large fragment(ORIF. Comminuted(ex fix B. Ulnar articular surface- Small fragment(excise (open or with scope). Large fragment(ORIF, Comminuted( triple choice. Chondral( debride vs. triple choice C. Ulnar styloid fractures =avulsion fracture of the major stabilizing ligaments of the distal ulna

-nonunion may result in painful limited rotation ad grip weakness RX: If < 2mm displacement, SAC with interosseous molding at neutral, slight ulnar deviation. If > 2mm displacement, ORIF with intraosseous (24 g or larger) compression wire and LAC x 6 weeks. -For painful late non-union, injection test. If positive and DRUJ stable (demonstrated with fluoroscopy/plain film with deviation, rotation, traction), then simple shell-out excision of fragment. If DRUJ unstable, then ORIF. See surgical techniques. 2. joint disruption (acute, <3 months) A. tfcc disruption with fractures/other dislocations(CR & immobilize (midrotation, slight ulnar deviation and palmar flexion), if fails(repair TFCC (or ORIF styloid) + RX other injuries -Essex-Lopresti=radial head fx with injury to interosseous membrane and TFC. RX: ORIF radial head/excise and prosthesis if comminuted, and reduce, repair, & pin DRUJ. B. tfcc disruption (isolated)(CR and immobilize. Supinate if ulna dorsal, pronate if volar, then LAC x 6 weeks. ORIF if dislocation locked or reduction incongruous. Open DRUJ (see surgical techniques) and repair necessary structures, LAC 6 weeks. C. TFC tears (no instability)- Symptoms: pain, click, lock, transient instability. RX: Positive or neutral variant(debridement and ulnar shortening. Minus variant(debridement 3. Joint disruption (Chronic, > 3 months and no arthritis) -tender over TFC/DRUJ, decreased ROM, instability/subluxation on exam and x-ray. A. TFC tears-no instability (RX as in 2C) B. TFCC disruption (recurrent dislocation or instabililty)-isolated(repair by styloid or TFCC reattachment if possible. If not, TFCC reconstruct. Bowers: ―no excellent procedures available.‖ All contraindicated if malunions, length discrepancies, arthrosis present and can not be simultaneously corrected. Bowers technique: palmaris graft around ulna and through ulnar tunnel, then through dorsal and volar radial tunnels and to Tq. Hui, Linscheid technique: distally based strip FCU through ulnar tunnel; consider pronator advancement. -if assoc. with translational shaft deformity( 3B plus radial angular osteotomy with graft -if assoc. with rotational shaft deformity( 3B plus rotational osteotomy or triple choice 4. Joint disorders A. Ulnar impaction syndrome, cased by length discrepancy (ulna positive) --Diagnosis: HX-ulnar wrist pain. PE: pain with ulnar deviation, rotation. Clicks, crepitus, tenderness at TFCC. Shuck LTq to R/O instability. Also shuck and compress DRUJ to R/O OA. XRAY: ulnar positive (may need comparison grip loaded films). Sclerotic cystic changes in lunate or ulnar head. Look for DRUJ OA. MRI or arthrogram: TFCC tear. L-Tq tears frequent. MRI may also show signal changes in L, Tq, ulnar head. PREDISPOSING CONDITIONS: premature radial epiphyseal closure from trauma, premature wrist fusion, excision radial head or shaft, radial shortening after fracture, thick TFCC (and ulnar neutral or negative). - TREATMENT: surgery if symptoms severe enough. Consider ulnar epiphyseal arrest in child. In adult with no OA, Milch shortening osteotomy (see surgical techniques)-88% good-excellent results-Linscheid, Hand Clin, ‗87. May consider Feldon Wafer procedure (2-4mm wafer removed just under TFCC. Open or through scope). Scope and deal with TFCC tear first.

B. DRUJ OA or incongruous( triple choice. Arthritis of the distal ulna -Diagnosis: H & PE: painful rotation, compression and shuck tests. Xray: marginal osteophytes, articular incongruity -Surgical alternatives: excision of distal end of ulna (Darrach), modification of Darrach, hemiresection interposition arthroplasty, resection and replacement arthroplasty (Swanson), DRUJ arthrodesis with proximal ulnar pseudarthrosis (Sauve-Kapandji), arthrodesis -Darrach (excision of distal end of ulna): may cause ulnocarpal instability-may not want to use in young non-rheumatoid. May want to use in advanced RA, or in ulnar impaction where DRUJ surfaces will not allow ulnar shortening. See surgical techniques. -Sauve-Kapandji (DRUJ arthrodesis with proximal ulnar pseudarthrosis): better than Darrach for younger, more vigorous patient. Indications: OA, younger RA with ulnar translocation, RA who need stable radioulnar surface to support arthroplasty or implant, non RA with DRUJ subluxation or dislocation when ulnar shortening or reconstruction not feasible. See surgical techniques. -hemiresection interposition arthroplasty (HIT) -arthrodesis: for paralytic instability, spastic rotational contractures. Carroll-Imbriglia technique: distal ulnar resection, fix to slot in radius with 2 lag screw. 5. other disorders A. Snapping or dislocating ECU. RX: immobilize if acute (pronation, slight DF and RD).Spinner/Kaplan stabilization if fails or chronic: flap of extensor retinaculum wrapped around ECU. B. Fixed rotational deformity -no motor control of rotation(radioulnar arthrodesis -acceptable motor rotation(soft tissue release; triple choice; or Baldwin CHAPTER 31 – ACUTE INFECTIONS GENERAL PRINCIPLES – If no abscess yet (just cellulitis), start empiric antibiotics and splint and rest. Most common organism: Staphylococcus aureus. Use 1 g IV Kefzol q 8 hours for Staph and PCN G 2 million U IV q 4 hours for Streptococcus and anaerobes; or Unasyn 1.5-3 g IV Q6 hours. Once cultures and sensitivities known, antibiotics can be changed. Best to give IV initially; can be changed to oral after 2-3 days—total of 7-10 days, unless osteomyelitis. If abscess, then I&D. Use tourniquet; elevate extremity, but do not exsanguinate (may force bacteria into rest of body). Use extensile incisions: volar zig zag approaching flexion creases at 45 degrees or less. Leave open and pack, wet to dry dressing changes after 48-72 hours and exercises. ACUTE PARONYCHIA = infection of the soft tissue fold around the fingernail. Most common infection in the hand. Usually Staph a. introduced from sliver of nail or hangnail, tooth. If no pus, treat with oral antibiotics, warm saline soaks and rest. If pus, I&D under digital block. Method depends where pus is. May need to remove portion of nail, or make 1 or 2 longitudinal incisions from edge of nail to base of nail-use #11 blade and point away from nail bed and matrix. Pack open; remove and start warm saline soaks after 48 hours.

CHRONIC PARONYCHIA – more difficult to eradicate than acute. Usually caused by Candida albicans in chronic maceration and obstruction of the fold. Most common in women, hands in water with irritants, diabetics. RX: Topical steroids and antifungals, eliminate moist environment. If that fails, then perform eponychial marsupialization: remove crescent shaped layer of skin superficial to germinal layer. FELON = subcutaneous abscess of the distal pulp. Often but not always from penetrating injury. May lead to osteomyelitis, skin necrosis, DIP septic arthritis. RX: I&D through lateral longitudinal incision (ulnar for digits 2-4, radial for 1&5), pack open, wet to dry dressing changes after 2 days. HERPES SIMPLEX = HERPETIC WHITLOW = viral infection of fingertip. Often in medical/dental workers, children. Differentiate from paronychia or felon. PE: erythema, tender, vesicles with fluid, bullae, hemorrhagic areas, encrusting. DX usually clinical, but may get immunofluorescent titer of serum antibodies for herpes simplex. RX: Nonoperative; it is selflimiting and resolves in 3-4 weeks. I&D contraindicated; may lead to secondary infection. DEEP SPACE INFECTIONS IN THE PALM WEB SPACE (―COLLAR BUTTON‖) ABSCESS-RX: Zigzag incision on palmar surface from web to distal palmar crease. Identify and protect digital nerves and arteries. Divide transverse metacarpal ligament and palmar fascia fibers. Make separate 1.5 cm dorsal longitudinal incision and connect the two wounds. Pack open. PALMAR SPACE INFECTIONS MIDPALMAR SPACE INFECTIONS-Can result from penetrating wound, rupture of septic tenosynovitis, or distal palmar abscess. MIDPALMAR SPACE: deep to flexor tendons volarly to interossei fascia dorsally. Radial border is 3rd metacarpal to midpalmar (oblique) septum and ulnarly hypothenar fascial septum. Distal margin: palmar fascia vertical septum 2 cm short of webs and proximally end of carpal tunnel. RX APM: Longitudinal approach from slightly curved incision made in the midpalm, beginning just proximal to distal palmar crease in line with 3rd ray and extending proximally and slightly ulnarward, parallel to thenar crease. Split palmar fascia, protecting superficial palmar arch and digital arteries and nerves. Identify 4th flexor tendons and enter space on either side of tendon. THENAR SPACE INFECTIONS- THENAR SPACE: located radial to 3rd metacarpal and midpalmar septum and extends to lateral edge of adductor pollicis. RX APM: dorsal longitudinal incision from web proximally. Bluntly dissect between 1st dorsal interosseous and adductor pollicis. 2nd incision on palm adjacent to and parallel to thenar crease. Avoid damage to subcutaneous palmar cutaneous branch of median nerve and median nerve motor branch. Blunt dissection to adductor pollicis. Drain each separately x 48 hours. HYPOTHENAR SPACE INFECTIONS- HYPOTHENAR SPACE: hypothenar muscles. Extrememly rare infection. RX APM: palmar longitudinal incision, from wrist crease distally 3 cm in line with ulnar border of 4th ray. Spread through hypothenar fascia.

PYOGENIC FLEXOR TENOSYNOVITIS (FLEXOR TENDON SHEATH INFECTION) – -caused by penetrating injury or hematogenous; usually Staph aureus -Kanavel signs 1) flexed digit 2) sausage digit 3) tender sheath 4) pain with passive stretch -RX: If caught in 1st 48 hours, IV antibiotics, hand splint, and elevation. Surgery if not better in 48 hours or if seen after 48 hours onset. -SURGERY: zigzag or transverse incision made just proximal to A1 pulley and sheath is opened. 2nd incision made on ulnar midaxial side of finger at DIP. Open sheath dorsal to neurovascular bundle just distal to A4 pulley. Insert 16 gauge catheter under A1 pulley 2 cm and irrigate. May suture in catheter and drain out distal end and flush with 50 cc NS q2 hours x 48 hours. For thumb, proximal part of sheath exposed through thenar crease incision; distal cm of transverse carpal ligament incised to allow access to FPL passage; catheter placed there. ULNAR AND RADIAL BURSAL INFECTIONS -ulnar bursa is extension of FDP sheath from 5th digit. Radial bursa is extension from FPL and goes to forearm. If tendon sheath infection not treated properly, can spread to these bursae. If they connect, then ―horseshoe abscess‖. RX: ULNAR-distal incision is same as sheath‘s proximal incision. 2nd incision is straight or zigzag at volar ulnar surface of wrist just radial to FCU, N/V/FCU retracted ulnarly, and FDS & P retracted radially. Bursa incised. Saline flushed from distal end. RADIAL-Proximal incision just ulnar to FRC. GANGRENOUS INFECTIONS -from a variety of anaerobic organisms: Clostridium: classic gas gangrene. Streptococcus: Meleney‘s infection, a rapid swelling, gangrenous infection in digit after insignificant puncture wound. -RX: open, culture, I & D, leave open, antibiotics. BITES -May need to extend, culture, I & D, leave open. RX: IV Kefzol and PCN; PO Augmentin 500 mg Q12 hours (see general principles) Make sure rabies and tetanus UTD. -Human bites - often over and into MCP joint after punch in mouth. Most common pathogen: S. Aureus. (Streptococcus viridans most common: Tonta, Kimble. Aust NZ J Surg 2001;71:467471). Also frequent is Eikenella corrodens, an anaerobic gram-negative rod. -dog or cat bites may have Pasturella multocida, a gram-negative coccus (responds to Unasyn and Augmentin) OSTEOMYELITIS -Most commonly S. aureus. From adjacent wound, joint, or tenosynovial infection, or direct penetration, or rarely hematogenous. -RX: may need to I & D: curettage if soft, or drill holes and remove window to decompress and remove all infected bone and sequestra. Pack open, antibiotics. Approaches: phalanges: midaxial incision. Metacarpals: dorsal approach. PYOGENIC ARTHRITIS -from penetrating trauma or adjacent bony or soft tissue infection.

-RX: rapid I & D to prevent articular cartilage destruction by lysozymal activity. IP and MCP joints entered through a longitudinal dorsolateral incision and incise dorsal to collateral ligament. Pack open 48-72 hours. SEPTIC BOUTONNIERE -a complication of pyogenic arthritis of PIP, if delayed treatment. Pus escapes dorsally through thin dorsal capsule and destroys extensor mechanism; lateral bands slip volarward away from eroded central slip. RX: I & D infection and clear 1st. Then reef extensor tendon and replace lateral bands dorsally if tissue available. Splint PIP extended 6 weeks with MCP and DIP motion. If extensor mechanism unsalvageable, then fuse PIP and transect extensor tendon distal to triangular ligament but proximal to oblique retinacular ligament. CHAPTER 32 – CHRONIC INFECTIONS (Patel) -Chronic hand infections are rare; may be caused by virus, bacteria, mycobacteria, fungi, protozoa, prototheca, parasites -Can affect skin, nails, SQ, tenosynovium, joints, nerve, bone -Primarily a problem of diagnosis; need early biopsy GENERAL PRINCIPLES DIAGNOSIS -To make diagnosis, must consider chronic infection in DDX -Nodule, abscess, ulcer, sinus, fistula, mass/tumor: all suspect -Initial appearance of lesion is nonspecific -Suspect in the immunocompromised: steroid or cytotoxic therapy, organ transplantation, hematologic malignancies, chronic renal failure, diabetes, alcohol abuse, old age, neutrophil count less than 55 / ml, malnourished (serum albumin level less than 3.5 g / dl) -MUST SEND TISSUE GUIDELINES FOR BIOPSY AND CULTURE -Imperative to alert pathologist and microbiologist of possibility of chronic infection -Open biopsy is best; organisms infect tissues. Obtain adequate material since chronic lesions contain few organisms. Sample several parts of the lesion; if initial results are negative, may have to repeat. -Biopsy specimen bisected; half sent to microbiologist in a sterile container without formalin. Also send pus, fluid. Send specimen in formalin to pathologist. -When possible, obtain specimen before antibiotics administered -To microbiology, ask for: stain, cultures & sensitivities for bacteria, mycobacterium, and fungi. Send for smear and stain: (1) Gram stain (for bacteria), (2) Acid fast bacillus stain (for mycobacteria), (3) Fungus KOH stain. Send for culture/sensitivity: (1) aerobic & anaerobic (bacteria), (2) acid fast culture at 30 and 37 degrees C, (3) Mycotic culture media Sabouraud‘s & silver stain.

-Tissue should be promptly forwarded to laboratory TREATMENT PRINCIPLES -Antibiotics reduce dose of organisms, but final elimination determined by phagocytosis & humoral immunity -RX: Antibiotics, surgical debridement of infected tissue, and improved nutrition -If patient is therapeutically immunosuppressed and does not respond to treatment, then temporary reduction in immunosuppressive therapy may be required BACTERIAL INFECTIONS ACTINOMYCOSIS -Caused by Actinomyces israelii, normally found in mouth. -May be from punch to mouth, dental workers occupational risk -Starts as abscess but evolves into painless and persistent swelling,, hard mass/induration. Can spread into tissue planes and eventually bone. ―Yellow granules‖ may drain from wound -RX: PCN x 6-12 months. If PCN allergic, consider TCN, erythromycin, clindamycin, amoxicillin, minocycline CAT SCRATCH DISEASE (=CSD) -Small erythematous lesion for weeks. -Caused by Rochalimaea henselae, a gram-negative bacillus -DX: Hainer‘s Criteria: (1) history of cat scratch, (2) regional lymphadenopathy, (3) positive skin test (serologic evidence of antibodies to R. henselae), (4) necrotizing granuloma, (5) gramnegative, silver-staining bacilli on lymph gland aspiration. 3 clinical or 1 clinical and positive biopsy are needed for CSD DX. -RX: Self-limiting, RX is controversial. Ciprofloxacin & trimethoprim/sulfamethoxazole have been used. MYCETOMA (ACTINOMYCETOMA, EUMYCETOMA) -Mycetoma is not 1 disease, but can be caused by a number of different bacteria or fungi -Mycetoma = cutaneous & SQ granuloma with abscesses, sinuses, and fistulas that drain granules (bacterial: red/yellow, fungal: black) ACTINOMYCETOMA = mycetoma caused by actinomycetes (bacteria) EUMYCETOMA = Mycetoma caused by fungus *Important to differentiate between actinomycetoma and eumycetoma because treatment is different DIAGNOSIS -Usually from traumatic implantation of etiologic agent from soil into bare hand. 3 stages: (1) Nodular stage (small, painless SQ nodules), (2) sinusoidal stage (abscesses which drain through sinuses), (3) musculoskeletal stage (spreads to fascia, muscle, bone) -Pain is not a predominant symptom -DDX: Tuberculosis, syphilis, sporotrichosis, blastomycosis, botryomycosis, coccidioidomycosis -TREATMENT: ACTINOMYETOMA: intramuscular streptomycin sulfate & either oral Bactrim DS 1 QID or Dapson or Rifampin. EUMYCETOMA: Ketoconazole or fluconazole. Surgical excision to clear margin if antifungal agent not successful

SYPHILIS PRIMARY SYPHILIS: occur on fingertips as ulcer (chancre) or ulcerative paronychia; acquired from mouth, teeth, genitals by direct contact. SECONDARY SYPHILIS: syphilitic dactylitis. TERTIARY SYPHILIS: gummas = chronic granulomatous lesion from skin to bone. CONGENITAL SYPHILIS: syphilitic dactylitis manifested by hand edema; may have pathologic fractures SEROLOGIC TESTS: Treponemal tests (FTA-ABS = fluorescent treponemal antibody absorbed test) & nontreponemal tests (VDRL = Venereal Disease Research Laboratory Test, and RPR = Rapid Plasma Reagin Test) DARKFIELD EXAMINATION: of exudates for Treponema pallidum TREATMENT PRIMARY SYPHILIS (CANCRE): 1 dose of 2.4 million units of IM benzathine penicillin G. (If PCN allergic, then doxycylcine 100 mg PO BID x 2 weeks) SECONDARY & TERTIARY SYPHILIS: Benzathine penicillin G 2.4 million units IM Qweek x 3 weeks CONGENITAL SYPHILIS: PCN & protective splints TULAREMIA -Caused by Francisella tularensis -Usually contracted by breaks in skin while handling infected animals or transmitted by insect bites -Ulcer, suppuration of lymph glands -DIAGNOSIS: Foshay skin test; culture on egg yolk, guinea pigs, dextrose cystine agar -TREATMENT: Gentamycin or streptomycin. No surgery except if glands greatly enlarged FUNGAL INFECTIONS -3 anatomic categories: cutaneous, SQ, deep CUTANEOUS FUNGAL INFECTIONS -3 anatomic categories: skin, paronychia, nail -Most identified on wet potassium hydroxide (KOH) preparation: skin or nail scrapings placed in 10% KOH on a glass slide, heated until bubbles seen, spores or branching mycelia confirm fungi SKIN – Most common: Trichophytosis (commonly called ―tinea‖ or ―ringworm‖. Candida albicans occurs in palm/webs of ―clenched fist‖ in spasticity. DIAGNOSIS: requires fungal cultures. TREATMENT: Uncomplicated tinea: cream or lotion of tolnaftate (Tinactin), miconazole (Monistat), ciclopirox (Loprox). Widespread lesions treated by: oral griseofulvin, ketoconazole, or itraconazole. In patient with rigidly clenched fist, tendon lengthening may be needed

CHRONIC PARONYCHIA -Candida albicans causes 70-97% -Occurs if hands frequently immersed in water, also children sucking digits -DIAGNOSIS: Disfigured, thickened eponychial skin; indurated, retracted cuticle; nail grooves from damaged germinal matrix. Nail may have discoloration from secondary bacterial infection (Proteus or Pseudomonas, which are normal flora in hyponychial space) which may require oral antibiotics. Detection of C. albicans may have to be from culture -TREATMENT: Keep digits dry. Apply topical antifungal such as tolnaftate or clotrimazole. If this does not work, consider marsupialization (removing fibrotic SQ tissue of the eponychium, which is a reservoir of fungus) TECHNIQUE OF MARSUPILIZATION -Digital block, finger tourniquet. Crescent-shaped block of skin & SQ tissue excised a few mm from the nail fold. Wound left open, warm soaks/H2O2 post-op. Keep fingers dry to prevent recurrence. CHRONIC ONCHOMYCOSIS (Nail plate & nail bed infections = tinea unguium) -Most common cause: Trichophyton rubrum. 2nd most common cause: C. albicans. -Presentation: starts as yellow/white spot, nail thickens, eventually may discolor from secondary bacterial infection. May separate from nail bed. -Treatment: Important to culture. C. albicans responds to: topical nystatin, miconazole, econazol; oral ketoconazole, itraconazole, griseofulvin. If nail extensively involved, may need nail plate removal and topical antifungal agent BID until new nail grows (4-6 months) SUBCUTANEOUS FUNGAL INFECTIONS SPOROTRICHOSIS – Caused by Sporothrix schenckii; occurs in rose growers & gardeners -Presentation: initial lesion is papulonodular, then ulcerates, linear lymphangitis & seropurulent discharge. Painless lesions; may heal then re-form for many years. -Diagnosis: Standard stains may not show organism. Specific fluorescent antibody staining may show. Grow on modified Sabouraud‘s agar fungal culture at 30 degrees C. -Treatment: Itraconazole (100-200 mg/day)-treats cutaneous and lymphocutaneous. Formerly treated with Saturated Solution of Potassium Iodide (SSKI, 1g/ml) (only treats cutaneous). As adjunct, consider damp heat (20-40 min., 2-4x/day) DEEP FUNGAL INFECTIONS -Infectious disease consultation recommended ASPERGILLOSIS – Aspergillus fumigatus is most common pathogen. Usual presentation is in a child undergoing chemotherapy for acute leukemia with hemorrhagic vesicle, bleb, or ulcer on upper extremity. KOH prep: numerous fungal hyphae. Biopsy is essential. -Treatment: Radical surgical debridement and IV amphotericin B. Spread to other sites is rapid and can be fatal. BLASTOMYCOSIS -Caused by Blastomyces dermatitidis. Immunocompromised host who works with soil.

-Skin lesions: SQ nodules, abscess, draining fistula -Osteoarticular lesions: septic arthritis, osteomyelitis -May need special stain (periodic acid Schiff stain) -Treatment: Ketoconazole or amphotericin B CANDIDIASIS -Tenosynovitis with C. albicans is rare; occurs in AIDS -Treatment: combined (amphotericin B and 5-flurouracil) and radical tenosynovectomy COCCIDIOIDOMYCOSIS -Coccidioides immitis has predelection for synovium. Presents with diffuse swelling on dorsal and/or volar wrist/palm -Diagnosis by positive coccidioidin complement fixation titer, positive coccidioidin skin test, synovial stains and cultures -Treatment: Tenosynovectomy and IV amphotericin B (use miconazole if compromised renal failure) -May have recurrences despite adequate RX. Consider prophylactic antimicrobials before cancer chemotherapy CRYPTOCOCCOSIS -Cryptococcus neoformans is on normal skin. Can cause tenosynovitis. RX: synovectomy and amphotericin B HISTOPLASMOSIS -Histoplasma capsulatum leads to tenosynovitis, CTS, arthritis. Treatment: tenosynovectomy and amphotericin B MUCORMYCOSIS -Caused by Rhizopus, Mucor, Absidia. -Diagnosis: Presents with vascular thrombosis and gangrenous tissue necrosis, black eschar and black pus. History of contaminated wound from soil or water. -Treatment: Surgical debridement, skin grafting, amphotericin B (alternative: fluconazole). Amputation if unsalvageable SPOROTRICHOSIS -Bone, joint, tenosynovial involvement -Treatment: Surgical debridement and amphotericin B (or keto- or itraconazole) HANSEN‘S DISEASE (=LEPROSY) -Caused by Mycobacterium leprae -Affects skin and peripheral nerves -Rifampin renders patient non-infective in 2 days, dapsone in 6 weeks -Mycobacterium leprae: acid-fast bacillus (AFB) identified by Armauer Hansen form Norway in 1872

-Grows in nerves in cooler parts of body (<37 degrees C): fine terminal dermal nerves, small SQ nerves, superficial nerve trunks EPIDEMIOLOGY -2.4 million people infected worldwide; 7,000 in U.S., mostly immigrants -Transmission from nasal droplet CLINICAL PATHOLOGY -Infects peripheral nerves; although skin lesions are usual chief complaint, nerve lesions are crippling -2-7 year incubation period -90% people are naturally immune; few people contract HD -Target cell: Schwann cell EARLY DIAGNOSIS -If made with slit skin smear and treated, patient can be cured and live a normal life CARDINAL SIGNS -Positive diagnosis = 2 of first 3, or 4: (1) skin lesions with anesthesia, (2) thickened nerve, (3) skin lesion (copper in light skin, hypopigmented in dark skin), (4) acid-fast bacillin slit skin smears CLINICAL EXAMINATION SLIT SKIN SMEARS – Clean skin with ether, pinch lesion to blanch, cut skin 5 mm long, 3 mm deep to dermis. Scrape dermis and smear on 6-8 slides (do not get blood – will render slide useless) Ziehl-Neelsen stain. If negative, consider skin biopsy. SKIN BIOPSY – Clean skin with ether, anesthetize skin, cut 1 cm elliptical piece of skin, full depth of dermis to include SQ fat. Immediately immerse in fixative (―FMA‖ fixative = 40% formaldehyde 10 ml; mercuric chloride, 2 g; glacial acetic acid, 3 ml; water to 100 ml). Specimen transferred to 70% alcohol. After 2 hours (without washing in water) and may be left in alcohol indefinitely. Slides examined at 100X for M. leprae bacilli. -If biopsy for mouse foot pad test, place in small sterile bottle without additive, at 4 degrees C. -Viable M. leprae stain uniformly; dead stain irregularly. Morphologic Index = percentage of uniformly (live) staining bacilli; tells if disease active, response to treatment -Bacteriologic Index = number of bacilli (live and dead) in dermis. Does not fall in 1st 2 months of treatment because dead bacilli not cleared yet. NERVE BIOPSY: Needed if no skin lesion, if skin biopsy negative -Use thickened sensory nerve: radial nerve at wrist, cutaneous nerve in forearm or thigh, superficial peroneal nerve, sural nerve -TECHNIQUE: Bluntly dissect out nerve, make small nick in epineurium separate 1 or 2 fascicles for 1 cm and excise. If nerve is scarred, then remove a small wedge. Fixative: 10% buffered formalin. NASAL SCAPINGS: (or ―nose blow‖) to check if patient is infectious SWEATING TEST: Tests integrity of dermal nerves by presence of sweat. Inject intradermally 0.2 ml of 1:1000 solution pilocarpine into lesion, patient with iodine, dust with starch powder. Blue powder=sweat. CLASSIFICATION

Paucibacillary: bacilli seen in 100 (100x) fields Multibacillary: anything more than pauci TREATMENT -Positive diagnosis must be made; not a diagnosis of exclusion OBJECTIVES OF TREATMENT -Elimination of bacteria (antimicrobial agents) -Pain relief (aspirin for mild reactions; corticosteroids, clofazimine, thalidomide for severe reactions; nerve decompression if meds do not work or nerve abscess) -Preserve sensibility (corticosteroids and nerve decompression) -Prevent / correct flexible / fixed deformities (hand therapy, reconstructive surgery) -Rehabilitation (psychological, social, vocational, avocational) MULTIDRUG THERAPY (MDT) – recommended by World Health Organization (WHO) to prevent drug resistance TREATMENT PAUCIBACILLARY Hansen‘s disease -Dapsone 100 mg PO QD, unsupervised and Rifampin 600 mg PO Qmonth supervised x 6 months TREATMENT MULTIBACILLARY HANSEN‘S DISEASE -As above, plus Clofazimine 50 mg PO QD unsupervised and Clofazimine 300 mg PO Qmonth supervised. -Duration: 24 months, then skin smears; continue until negative -Rifampin is expensive. Recommended dosing in U.S. is 600 mg PO QD if tolerated (hepatotoxic-check periodic bilirubin and stop if elevated) -Clofazimine discolors the skin (may have compliance problem) PAIN RELIEF Pain from neuritis, infection, tenosynovitis, arthritis, dermatitis, reactions REACTIONS IN HD (Lepra reactions are medical emergencies. Must be treated in 24 hours to avoid irreversible sensory loss) Lepra Type 1 Reaction: neuritic pain, motor and sensory loss, inflammation of skin lesions, tenosynovitis Lepra Type 2 Reaction: painful papules, ulnar nerve neuritis, fever, lymphadenitis Lucio‘s Reaction: Common among Mexicans. Large recurrent, sloughing ulcerations which heal poorly TREATMENT OF REACTIONS -Mild Type 1 or 2: ASA -Severe Type 1 or 2 (severe pain, nerve deterioration, acute tenosynovitis): Prednisone 60 mg QD, taper over 2-3 months. Clofazimine 300 mg QD until controlled off prednisone, then taper to 100 mg QD. Thalidomide only for Type 2 (and only if not woman of childbearing age): 100 mg QID, tapered off after reaction controlled. For chronic reaction, 100 mg QOD to BID. Attempt to d/c every 6 months. -Lucio: 60 mg predinisone QD, attempt to taper over several weeks. QOD for chronic reactions. MDT. Debride sloughing skin, skin graft. -Tenosynovitis: prednisone, hand

elevations, splinting/mobilization NERVE LESIONS (either chronic nerve compression syndrome or nerve abscess) -2 major indications for operating on nerves in HD: (1) Relieve pain, (2) Preserve sensibility -Ulnar nerve decompression is most common surgery with best results (77-99% pain relief; 50% with motor and sensory recovery, motor occurring 6-12 months post-op) -Results CTR disappointing; radial nerve release (in radial groove) equivocal TECHNIQUE OF ULNAR NERVE DECOMPRESSION -See Ch. 44 – submuscular anterior transposition may maintain warmer environment that may reduce bacteria -Longitudinal epineurotomy along length of enlarged nerve. If epineurial sheath springs open and fluid escapes, then ½ epineurium peeled off (hemiepineurotomy), leaving blood vessels intact. NERVE ABSCESS -Fluctuating abscess needs drainage; relieves pain and may help function. Excise draining sinuses. PRESERVATION OF SENSIBILITY -Loss of pain allows patients to damage and deform themselves -4 causes of sensory loss: (1) silent neuritis, (2) acute neuritis from infection, (3) acute neuritis from immunologic reaction, (4) nerve abscess -Treatment of 1st 3: prednisone, clofazimine; if medications do not work, then surgical decompression SURGICAL TREATMENT OF DEFORMITIES -The horror and stigmata of Leprosy is rooted in deformity -Motor nerve palsy causes muscle imbalance and flexible (early), then fixed (late) deformity -Sensory nerve palsy causes loss of tissue (shortening) due to unrecognized trauma, infection, necrosis -Autonomic nerve palsy results in dry skin and subsequent cracks and fissures -Deformity occurs in 25% HD patients -Ulnar nerve responsible for 50% hand deformities -Before operative treatment, criteria must be met: (1) disease is inactive and controlled by drugs, (2) deformity is stable, (3) skin is not infected, ulcerated, (4) PIP arthrodesis done before tendon transfers (if both needed) SUPPLE DEFORMITIES -Tendon transfers (see Chapters 47-50) FIXED DEFORMITIES -Splint first DIP -If contracted flexion deformity, then arthrodesis (see Chapter 4)

-If distal phalanx partially missing so that arthrodesis impossible, then Fritschi ―pulp-plasty‖: DIP exposed through dorsal incision, dorsal capsule and volar plate excised, FDP transected, joint surfaces trimmed and fused -May get lateral deviation from pathologic fracture requiring middle phalanx osteotomy and wedge resection PIP -Can usually be treated with hand therapy. If release requires > 1 cm of skin length, then consider cross finger graft (bed too poor for free graft) -If collaterals short/contacted, then excise. May not be able to fully extend due to questionable distal circulation -Skin graft takes in 10 days, ROM then started -Sever pedicle skin flap in 15 days, then ROM INDICATIONS PIP ARTHRODESIS: (1) Painful bony ankylosis; in poor position, (2) subluxation, (3) PIP in lateral deviation. Use mid-lateral incision and hold with 1 axial K-wire MCP -Claw hand: If joint space normal, then release dorsal skin, capsule, collateral ligaments, and FTSG. Immobilize MCP in flexion with K-wire. Consider subarticular osteotomy of metacarpal necks to improve ROM THUMB -If IP severely contracted (flexed) and subluxed, then consider arthrodesis in slight flexion -MP arthrodesis indicated if MP hypermobile and unstable and IP mobile -CMC rarely deformed. If subluxed in adduction, then consider 1st and 2nd intermetacarpal fusion with iliac crest graft. -For shortened thumb, consider web space deepening or phalangization (see Chapter 66) SKIN DEFORMITIES -Ulcerations: Treat with wound care, immobilize in position of function, give antibiotics if infected -Dry skin: 15 minute water soaks; oil / lotion REHABILITATION -Important to involve leprologist, physical and/or occupational therapist, social worker

RESOURCE -Gillis Long HD Center (800-642-2477)

MYCOBACTERIAL INFECTIONS -Tuberculosis is most common chronic hand infection -From typical and atypical mycobacteria

-Need to biopsy! Imperative to request R/O mycobacterial infection and request cultures at 30 (for M. marinum) and 37 degrees C. -Found in 5 tissues: (1) skin / SQ, (2) tenosynovium, (3) joints, (4) bone, (5) combination

CUTANEOUS TUBERCULOSIS -Nontender nodule progresses to single/multiple abscesses that drain clear fluid. May have erythema, swelling, ulceration, crusting, lymphatic spread (70%) -Usually inoculated in minor injury (i.e. M. marinum: ocean, fish tank) -Does not heal with antibiotics, soaks TREATMENT: M. tuberculosis: isoniazid and rifampin QD x 6 months, ethambutol for 1st 2 months. M. marinum resistant to isoniazid, so rifampin-ethambutol combination best for 6 months minimum. TUBERCULOUS TENOSYNOVITIS -Most frequent tuberculous infection in hand -Clinically simulates rheumatoid tenosynovitis -Flexor tendons affected more often than extensor ->50% M. marinum, M. kansasii 2nd most common -Patient healthy, afebrile, no imflammatory signs. Hand and CXR usually normal. DIAGNOSIS -Delay in diagnosis occurs for several reasons: (1) insidious, (2) nonspecific, (3) pain absent until late DIAGNOSTIC CLUES Tuberculous tenosynovitis should be suspected in the following situations: (1) After incision and drainage of a mass or synovectomy, draining sinus forms that does not respond to antibiotics, (2) ―compound palmar ganglion‖ or ―dumbbell tenosynovitis‖ dorsally, (3) chronic proliferative tenosynovitis that reappears after tenosynovectomy, (5) tenosynovitis made worse by cortisone injection, (6) CTS with proliferative / recurrent tenosynovitis in the absence of rheumatoid or collagen diseases, (7) ―Rice bodies‖ in synovial mass, (8) Mass erupting with serous fluid forming a chronic sinus that does not respond to antibiotics, (9) chronic granuloma: small focus of inflammation (if central area necrosed = caseating granuloma; characteristic of m. tuberculosis. Noncaseating granuloma is characteristic of atypical mycobacteria) 4 STAGES of Tuberculous Tenosynovitis: Stage 1: serous exudates; Stage 2 (2 years): granulation tissue and rice bodies; Stage 3: tendon necrosis with rupture at 4 years; Stage 4: spread to joints / bone. Diagnosis by biopsy, H & E, Ziehl-Neelsen, and Gomori methenamine silver stains and culture TREATMENT: Multidrug therapy is cornerstone of treatment. Synovectomy is controversial. If host is immunocompromised or mycobacteria is chemoresistant, synovectomy is indicated TUBERCULOUS ARTHRITIS -Less common than tenosynovitis

-Wrist most common, then finger joints, elbow -May resemble RA -Suspect if drainage persists despite I&D, antibiotics STAGES: Stage 1: infection of synovium (pain, swelling, decreased ROM); Stage 2: invasion of cartilage and subchondral bone with cysts, decreased joint space; Stage 3: deformed joint, subluxed/dislocated, ankylosed (+/- pain) TREATMENT -Stage 1 and 2: MDT and functional splinting / ROM. Synovectomy controversial (unless M. marinum); and unless unresponsive to 3 months of MDT or if recurrent -Stage 3: Arthrodesis (once stabilized, and after 9 months of MDT), arthroplasty, or corrective osteotomy TUBERCULOUS OSTEOMYELITIS IN CHILDREN: Dactylitis presents with painless, nonsuppurative, insidious hand/finger swelling. Later abscess may drain cheesy, yellow exudates. X-rays: endosteal resorption and spina ventosa (Latin: Spina = ―short bone‖, Ventosa = ―inflated with air‖) IN ADULTS: In phalanges and metacarpals. Present with local discomfort and swelling. May have pathologic fracture, fistula. X-rays: (1) honeycomb bone destruction, (2) spina ventosa TREATMENT: MDT. Surgical debridement needed if resistant organism and/or if immunosuppressed patient, otherwise not essential ANTI-TUBERCULOUS DRUGS CHEMOPROPHYLAXIS: Indicated if tuberculin positive contact of active case or anyone known to have converted in last 2 years (regardless of age): isoniazid 300 mg PO QD x 1 year. MULTIDRUG THERAPY (MDT) (Important to get Infectious Disease Consultation) -CDC recommends 6 months MDT for soft tissue extra-pulmonary TB, 9 months if bone/joint involved. 1st 2 months: isoniazid, rifampin, ethambutol, pyrazinamide; then ethambutol d/c‘d if bacillus sensitive to other 3. If resistant to rifampin, than 18-24 months of other 3. SPECIFIC (1st line) DRUGS -ISONIAZID (INH): Adult dose (QD): 300 mg PO, IM. Pediatric Dose (QD) 10-20 mg/kg (max 300 mg). Main Toxicity: hepatic toxicity, peripheral neuropathy (pyridoxine given conjointly to minimize neuropathy) -RIFAMPIN: Adult dose (QD): 600 mg PO, IV. Pediatric Dose (QD) 10-20 mg/kg (max 600 mg). Main Toxicity: hepatic toxicity -PYRAZINAMIDE: Adult dose (QD): 1.5 – 2.5 g PO. Pediatric Dose (QD) 15-30 mg/kg (max 2 g). Main Toxicity: hepatic toxicity

-ETHAMBUTOL: Adult and Pediatric Dose (QD) 15-25 mg/kg PO. Main Toxicity: optic nerve toxicity, (loss of visual acuity) **All tuberculous hand cases should be R/O‘d for pulmonary tuberculosis by CXR, sputum smear/culture. Pulmonary TB is highly contagious but non-infectious after 2 weeks of MDT SPECIAL FEATURES AND TREATMENT OF ATYPICAL MYCOBACTERIA -M. marinum: resistant to isoniazid. Sensitive to ethambutol, rifampin -M. kansasii: MDT: rifampin, isoniazid, ethambutol, erythromycin -M. avium-intracellulare complex (MAC) is the most resistant and tenacious organism that infects the hand (usually tenosynovitis). Treatment: thorough surgical debridement and MDT. Resistant to usual drugs. Use clarithromycin, rifabutin, ethambutol. Wide surgical exposure of tendons from M-T junction to terminal insertion. -M. chelonei: Treat with erythromycin, doxycycline, kanamycin -M. szulga: olecranon bursitis and CTS APM for chronic tenosynovitis where mycobacteria suspected: If biopsy reveals granuloma, then start M. tuberculosis treatment of isoniazid, rifampin, pyrazinamide, ethambutol until culture / sensitivity done (can take 1-10 weeks). Bone / joint lesions x-rayed Q3 months; if improvement not seen, then surgical debridement considered. OCCUPATIONAL INFECTIONS BARBER’S INTERDIGITAL PILONIDAL SINUS = foreign body hair granuloma (pilonidal from Latin: pilos = hair, nidus = nest) when customer‘s hair is implanted in interdigital skin of barber. -Pit/draining sinus/abscess forms on interdigital web space dorsally -Treatment: excision and primary closure SHEARER‘S DISEASE -Similar to above but with sheep shearers and wool MILKER‘S GRANULOMA -Similar to above but with milkers and cow hair PARASITIC INFECTIONS GNATHOSTOMIASIS -SQ infection by migrating larval nematode Gnathostoma spinigerum. Contracted by eating raw fish and pork. Common in Asia. Presents as multiple migrating episodes of swelling and pain in hand, foot, shoulder, face. Treatment: Surgically explore and remove larva (1 cm x 1 mm) ONCHOCERCIASIS -Rare infection of flexor tendons by filarial nemotode Onchocera volvulus. Treatment: synovectomy

PROTOTHECAL (ALGAE) INFECTIONS -Rare infection from algae genus Prototheca, after penetrating wound. Recurrent hand infection / abscess or olecranon bursitis after I & D. -Treatment: complete excision of abscess wall and oral tetracycline PROTOZOAL INFECTIONS -Leishmaniasis or ―oriental sore‖ after sandfly bite gives red, raised papule which forms an ulcer. Usually after travel to India or Africa -Treatment: antimony preparation. If does not work, then amphotericin B VIRAL INFECTIONS WARTS -Caused by human papillomaviruses (HPV‘s), only in epidermis, incubation 1-3 months

CLASSIFICATION -2 types: common wart (verruca vulgaris) 95%; flat (plane) wart (verruca plana) 5% DIAGNOSIS COMMON VERRUCATED WART – untreated, may spread FLAT (PLANE) WART – minimally elevated papules 2-5 mm MULTIPLE WARTS – rare, inherited. May transform into squamous cell carcinoma TREATMENT -No effective antiviral meds -Options: (1) keratolytic therapy, (2) surgical excision, (3) cryotherapy with liquid nitrogen or CO2, (4) bleomycin injection, (5) electrocautery, or laser -Spontaneous resolution in children: 50% in 1 year, 90% in 5 years. Therefore, less aggressive therapy recommended since likelihood of spontaneous resolution and lack of tolerance to painful, ablative treatment. -For immunosuppressed patients, lesions are progressive and malignant transformation more likely. This warrants Dermatology and Infectious Disease consultations APM: -KERATOLYTIC THERAPY: Mediplast (40% salicylic acid on tape), piece cut slightly larger than wart and taped; may reinforce with waterproof 3M tape and leave 1-2 days. Remove in shower and slough epidermis. Reapply when dry. Repeat until gone (may take weeks) -SURGICAL EXCISION: If patient wants quicker treatment. Excise with 1-2 mm margins. AIDS -Prone to opportunistic infections -HERPES SIMPLEX HERPETIC WHITLOW: Do not I & D; may cause viremia and fatal encephalitis. Treat with oral or IV acyclovir or IV foscarnet

-HERPES ZOSTER: median or ulnar nerve neuritis -MYCOBACTERIUM HAEMOPHILUM: may cause joint infection -BACILLARY ANFIOMATOSIS: Treatment: erythromycin 1-2 months -KAPOSI‘S SARCOMA = proliferation of blood vessels and entrapped RBC‘s -DIGITAL GANGRENE: from digital artery obliteration, chemotherapy vascular injury, HIVinduced thrombocytopenia (which can also cause compartment syndrome) CHAPTER 33 – MICROVASCULAR SURGERY (Pederson, Sanders) INSTRUMENTATION MAGNIFICATION LOUPES: 2.5 to 4.5X MICROSCOPE: Set up before exposure. Sit with feet flat, back straight, knees, hips, elbows bent 90 degrees. INSTRUMENTS FORCEPS: Adventitia with small teeth. Smooth-tipped jeweler‘s (2-course ( 5-delicate) SCISSORS: Straight and curved, blunt and sharp tipped DILATORS: Spring-type, Straight constant-diameter (lacrimal), tapering, Fogarty CLAMPS: For arteries or veins BACKGROUND IRRIGATION: Heparinized saline (most commonly used) or LR. 3-5cc syringe and 27-gauge angiocath. NEEDLE DRIVERS: Simple, curved nonlocking most commonly used OTHERS: Wecksel (small cellulose sponges), Bipolar (with standard and microtips), Small Weck hemoclips, Instrument demagnetizing coil SUTURES: 9-0 nylon on 100 micron needle for hand, 10-0 nylon on 75 micron needle for digital vessels. Tapered or cutting only at needle tips. LAB: Need to learn in lab. MODELS: Rubber glove stretched over Petri dish, fresh leaf, silicone tubing. Rat femoral and carotid similar to digital vessels. BASIC TECHNIQUES ESSENTIALS FOR PATENT ANASTOMOSIS: 1) Atraumatic dissection and handling 2) Normal vessel wall and intima (resect damaged tissue) 3) Good proximal flow 4) No tension 5) Remove overhanging adventitia 6) Do not suture back wall END-TO-END ANASTOMOSIS: Pick up adventitia only, not vessel end or intima. Place corner sutures first 120-180 degrees apart. Artery bite 1-2 x, vein bite 2-3 x vessel wall thickness. Needle enters 90 degrees to vessel to evert edge. Surgeon knot first throw, do not overtighten and tear vessel wall. Suture front, flip corners and suture back. For last suture, few options: 1) 2 neighboring sutures left long and pull traction 2) Pull suture on opposite wall away 3) Do not tie 2nd to last suture until last is placed 4) Harashina (Place like running last 2, then cut in middle and tie). After releasing clamp, ooze is normal, but pulsatile bleeding is not; needs additional sutures. PATENCY TEST CLINICAL MICROVASCULAR

TECHNIQUES SIZE DISCREPANCY: If 2:1, then DILATE smaller one. If 3:1, END-IN-END (smaller with flow into larger) or SPATULATION (Cut one or both vessel walls longitudinally and repair by triangulation). END-TO-SIDE for any discrepancy (more turbulence and thrombosis, however) ALTERNATIVE ANASTOMOSIS TECHNIQUES -BACKWALL-FIRST: -FLIPPING: Flip a mobile distal part (i.e. flap) -180-DEGREE VERTICAL: Corner sutures placed 180 degrees apart at mid front and mid back. Only need to rotate 90 degrees. -END-TO-SIDE: Used if cannot sacrifice donor vessel or if large size discrepancy. Make arteriotomy in donor vessel (hole-circular or elliptical). May use small vascular punch (smallest 2.4mm). Take off 90 degrees, or less. -CONTINUOUS SUTURE: Studies: no clear advantage interrupted over continuous. May run 2 halves (APM) -SLEEVE AND CUFF: =end-in-end NON-SUTURE TECHNIQUES -MECHANICAL: 3M ring-pin, comparable and faster than suture -LASER, GLUE: experimental

REVISION OF FAILED ANASTOMOSIS: -Reasons for failure: 1) Technical error with anastomosis, 2) Poor proximal flow from undetected damage or vasospasm, 3) Thrombus at anastomosis or clamp site -First 30 minutes critical for thrombus formation. If blood flow stopped, need to flood suture line with heparized solution before flow restored. -Perform anastomosis without tourniquet so flow can be evaulated -If have poor proximal flow, use local vasodilator and warming. If still poor, may need proximal exploration, dilation, or intraarterial vasodilator. VEIN GRAFTS: -If tension exists at anastomsis, use vein graft. -For digital work, use small volar subQ veins just proximal to wrist. -Dorsal hand veins and cephalic vein near wrist best for palmar and forearm vessels -Lower saphenous vein above ankle good for free flap pedicles. -Mark vein graft and reverse (valves) -Need correct length (vein grafts elongate after reperfused). If too long, may kink. Measure vein in situ before harvest. PROSTHETIC GRAFTS: -Nothing good out yet VENOUS DRAINAGE: -If poor venous drainage, may need to revise venous anastomosis if occluded. -Consider leeches if venous congestion (only if venous anastomosis occlusion ruled out) (Leeches feed and exude hirudin anticoagulant)

-Venous congestion usually resolves after 5-7 days MAINTAINING FLOW: -Fasciotomy if long ischemia time -Warm flap after anastomosis to reduce vasospasm -Achieve hemostasis to avoid hematoma -No compression: may need to leave partially open, or close loosely. If can‘t close, consider local flaps, skin grafting. -Monitor flow during closure to avoid pedicle compression -Place soft drains, not directly on vessels -Immobilize post-op, do not change dressing for 5-7 days. -Venous congestion more commonly a problem than inflow, so elevation usually prescribed -Most lost flaps have problems in first several hours post-op. Problems in first 12 hours usually due to technical problems at anastomosis. After this period, few flaps lost until 8-14 days—then due to infection/abscess. POST-OP: -Limited moving of patient for 3-5 days -Room warmed above 78 degrees F (replants and toe transfers only) -Private room; decreases emotional stress -Adequate pain relief -Prohibit smoking, caffeine, and chocolate for 5 weeks post op (may cause vasoconstriction) -Close post op exam (usually by surgical member) for 12 hours post-op (time most likely to thrombose) -Oxygen, adequate fluids, possible transfusion. No vasopressors. -Consider preop axillary block with an indwelling brachial sheath catheter for intra-op anesthesia, and also for post-op continuous Marcaine infusion for symathectomy effect and analgesia. FAILURE OF REPERFUSUION CRUSH AND AVULSION INJURY: -If no immediate reperfusion after anastomosis, check that proximal flow was verified, repair was technically well performed, and vasospasm was treated. If still with no reperfusion, make sure anastomosis was not made to a vein. Check to see if there was unrecognized vessel damage distally, which would require a vein graft. If there is severe crush, there may be disseminated coagulation in the distal part, which are usually not salvageable. REPERFUSION INJURY (NO REFLOW PHENOMENON): -Initial success with reperfusion, but gradually fails. Possible causes: ongoing arterial obstruction, arteriovenous shunting, alteration of the clotting mechanism, edema of vascular endothelium with narrowing of lumen, disseminated intravascular thrombosis, loss of physiologic integrity of capillary or venule wall, free radicals, hydroxyl radicals (OH). Superoxide dismutase (SOD) usually scavenges radicals, but can get overloaded. Some surgeons treat with allopurinol that blocks radical production. Use of fibrinolytic agents has been suggested, although no effect in vessels 0.8-1.5 mm.

MONITORING TECHNIQUES: Most important monitor is an experience observer. ToolsAPM: Laser Doppler. Others: temperature probes, transcutaneous oxygen, pH monitor, photoplethysmography. RESULTS: 15-25% failure, 20% need anastomosis revision. Study by Khouri, et al.: 496 free flaps, 23 surgeons: 10% postop thrombosis requiring re-exploration. Eventual overall flap failure = 4%. Only technical factor with positive effect was more than 1 vein per flap. Negative factorvein graft, heparin use (but could have more difficult cases). Different pharmacologic protocols made no difference. PHYSIOLOGY AND PHARMACOLOGY OF MICROCIRCULATION BASIC MECHANISMS: Poiseuille‘s law: F (flow) is proportional to (Pressure gradient/length)(radius cubed/fluid viscosity). Vessel wall smooth muscle is under sympathetic control. Local factors important: tight dressing, hematoma, edema. Adequate hydration maintains cardiac output, prevents shunting, prevents peripheral vasoconstriction, lowers blood viscosity. HEMOSTATIC MEHANISMS CASCADE PATHWAY HYPERCOAGULABILITY: Patient with cancer, premature atherosclerosis, Type II diabetes. All not good candidates for elective microvascular procedure. Consider heparin and long-term oral anticoagulation if non-elective case. PHARMACOLOGY OF SELECTED DRUGS **Most commonly used are aspirin and/or dextran for 3-5 days (good data lacking). In situations of damaged vessels, heparin is often added and continued for 5-7 days (until endothelium regenerates) ANTICOAGULANTS: HEPARIN: Indicated if vessel damage (crush/avulsion) or hypercoaguable patient. Numerous effects: activates antithrombin III, inhibits platelet aggregation, decreases fibrinogen clotting. ACETYLSALICYLIC ACID (ASPIRIN): Antiplatelet effect, 3mg/kg QD. DEXTRAN: used by authors-APM—500 cc dextran 40 in NS given over 6 hours QD for 3-5 days. Initial dose given prior to anastomosis since peak is 4 hours after infusion. Do not use if renal, cardiac, pulmonary disorders (osmotic complications of pulmonary edema or renal shutdown). Also do not use if < 15 y.o. (increase in bleeding). Mechanism not well understood, appears to have antiplatelet and heparin-like effects. Pharmacologically is a plasma expander. Dextran 1 may be given 1-2 min. before dextran as prophylaxis against severe anaphylactic reaction (20 cc (150mg/cc) IV over 1-2 min.) PROSTAGLANDINS: Not readily available VASODIALATORS TOPICAL AND INTRAARTERIAL AGENTS: -Lidocaine topically (4%) most common, others: magnesium sulfate, chlorpromazine, sodium nitroprusside, prostaglandins -Papaverine intraarterially to release vasospasm, others: Priscoline (tolazoline hydrochloride), nitroglycerin, reserpine, guanethidine

PHARMACOLOGY OF SYSTEMIC AGENTS: -METHODS OF DECREASING SYMPATHETIC TONE: -Stop production of neurotransmitter -----Decrease central stimulation (warm and calm environment) -----Proximal stellate block or sympathectomy -----Inhibit amine pump -----Deplete precursors -Block storage granule transport system (reserpine) or displace transmitter from axon terminal (guanethidine) -Block vesicle release (bretylium) -Block receptor uptake or effect of neurotransmitter -----Block alpha-receptor (prazosin, phenoxybenzamine) -----Block calcium channels of vascular smooth muscle (nifedipine) FIBRINOLYTIC AGENTS: Urokinase, streptokinase, tissue plasminogen activator may possibly used to salvage failing replant or tissue transfer. Embolizes distal clot. Requires intraarterial catheterization, and early administration. Should get hematology consult—may have life-threatening allergic reactions and bleeding complications. CHAPTER 34 – REPLANTATION (Goldner, Urbaniak) -Started in 1960‘s -Viability rates > 80% -Replantation = reattachment of a completely amputated part -Revascularization = repair of incompletely amputated part PATIENT SELECTION -Decision to replant not always easy -Anticipated function should be equal to or better than that achieved with revision of amputation or prosthesis -Guillotine-type amputations (uncommon) are ideal -Good candidates for replantation (but not absolute indications): (1) thumb, (2) multiple digits, (3) partial hand (through palm), (4) almost any part of a child, (5) wrist or forearm, (6) elbow and above elbow (sharply amputated or moderately avulsed), (7) individual digit distal to FDS insertion -Replantation should be considered in most thumb amputations -In multiple digit amputation, least damaged digits selected for replantations and often need to be shifted to most functional positions -To replant distal to DIP or thumb IP, need at least 4 mm of dorsal skin proximal to nail to repair veins, or use volar veins if more distal -Not favorable for replantation (but not absolute contraindications): (1) severely crushed/mangled parts, (2) amputations at multiple levels, (3) patient with serious other

injuries/disease, (4) severely arteriosclerotic vessels, (5) prolonged warm ischemia time, (6) adult with single digit amputation proximal to FDS insertion, especially index or small fingers. -Maximum warm ischemic times: (1) 6 hours if proximal to carpus, (2) 12 hours for digit. Cold ischemic time: 12 hours for proximal amputation -If multiply injured, amputated part (usually digit, where muscle preservation is not an issue) may be preserved at 4 degrees C for 24 hours. -If mentally unstable, and especially if self-inflicted; not good candidate -Special consideration for adult with single digit proximal to FDS: individuals where appearance important; or musicians—however, useful function usually not attained -Treatment of ring avulsions is controversial. Urbaniak classification: Class I: adequate circulation, Class II: inadequate circulation, Class III: complete degloving / amputation. --Treatment: Class III, especially if proximal to FDS insertion: completion amputation. However if distal to FDS, PIP and proximal phalanx intact, vein and nerve grafts can salvage. -In traumatic amputations, patient and family often desire replantation and expect miraculous results. Important to discuss chances of success; anticipated function; length of surgery, hospitalization, and rehabilitation; time lost from work / life vs. amputation / revision. INSTRUMENTS See Ch. 33 -3.5x to 4.5x loupes for initial dissection, then microscope of at least 20x essential for vessels distal to the elbow. -Appropriate needle/suture (monofilament nylon is best) for vascular repair. Distal digit: 50micron needle, 11-0. Proximal digit: 50-75 micron needle, 10-0 (most common). Palm 100micron needle, 10-0. Wrist / forearm 130 micron, 9-0. Proximal to elbow 8-0. SURGEONS -Should be able to achieve 90% patency in 1 mm vessels in animal laboratory -Need teams of surgeons: single uncomplicated digit may take 3-4 hours by an experienced team; multiple digits can take 15+ hours PREPARATION OF THE AMPUTATED PART FOR TRANSPORTATION -2 methods: (1) Immersion in Ringer‘s lactate or saline in a bag or specimen cup, then placed on ice (APM, because frostbite less likely, no strangulation by wrap, easier to instruct, maceration not a problem), (2) wrap in cloth moisten by LR or NS and placed on ice INITIAL SURGICAL MANAGEMENT -2 subteams: 1 for amputated part(s) and 1 for patient/stump(s) -AMPUTATED PART(S): Part(s) cleaned with Hibiclens and LR, place on bed of ice covered with sterile plastic drape. X-ray parts. Digits exposed with longitudinal mid-lateral (slightly dorsal) incisions on each side of amputated part and stump for approximately 2 cm. Reflect dorsal and palmar skin flaps and locate digital nerves and arteries in palmar flap and veins in dorsal flap. Tag nerves and vessels with hemoclips (very important

step). Debride soft tissue and bone and place 1 or more retrograde IM K-wires ready for reattachment. -PATIENT / STUMP(S): H&P; x-ray stump(s); labs CBC, PTT (poss. CXR, EKG, Chem, U/A, T&C); IVF, IV antibiotics, tetanus, foley. Axillary block and indwelling catheter with bupivicaine (Marcaine) to enhance peripheral blood flow by sympathetic block. TECHNIQUE AND SEQUENCE OF SURGERY (for digit/hand replantation): (1) Locate and tag vessels/nerves, (2) Debride, (3) Shorten and fix bone, (4) Repair extensor tendons, (5) Repair flexor tendons, (6) Anastomose arteries, (7) Repair nerves, (8) Anastomose veins, (9) Obtain skin coverage *Extremely important to locate and tag vessels/nerves before debridement -Also repair joint capsule, ligaments, lateral bands, etc. -In multiple-digit replants; overall duration of surgery decreased by ―structure-by-structure‖ repair as opposed to ―digit-by-digit‖ BONE SHORTENING AND FIXATION -Bone must be shortened so neurovascular tissues can be repaired where their level is normal; they cannot be repaired under tension -In the digit, 0.5-1.0 cm of bone normally resected. Proximal to the hand, 2-4 cm of bone. -Choices for bone stabilization: (1) 1-2 longitudinal IM K-wires (APM), (2) 1 longitudinal and 1 oblique K-wire, (3) crossed K-wires, (4) intraosseous wiring, (5) IM screws, (6) plate and screws -Important to check rotation in flexion; fingertips should point to scaphoid -Special indication for primary implant arthroplasty (silicone): clean amputation through PIP in piano player EXTENSOR TENDON REPAIR -2 horizontal mattress sutures of 4-0 polyester -Repair lateral bands (if needed) -If extensor tendons irrepairable, consider (1) extensor tendon grafting, (2) IP fusion (see Ch. 61, 62) FLEXOR TENDON REPAIR -Primary repair if possible, secondary procedures may be needed (see Ch. 59, 60) ARTERIAL REPAIR (see Ch. 33) -Repair both digital arteries and all possible arteries in partial hand/wrist amputations -Arterial repair not done until spurting blood flow from proximal vessel. Steps to induce flow (1) relieve compression, tourniquet, (2) resection to healthy vessel, (3) warm patient and O.R., (4) hydrate patient, (5) elevate blood pressure, (6) warm LR irrigation,(7) intraluminal flush with 1:20 papaverine, (8) check with anesthesiologist to correct metabolic problem (i.e. acidosis) -Only repair normal vessel and with no tension; use interpositional vein graft if large gap (used in 20%; harvest from volar wrist; 1-2 mm diameter; store in LR / papaverine solution) -Option to shift arteries -For thumbs, may vein graft from ulnar digital artery of the amputated thumb to the 1st dorsal metacarpal artery on the hand dorsum or end-to-side into radial artery at wrist.

-Tourniquet may (if needed) be inflated for each anastomosis and deflated -Microclips produce vessel damage; do not leave on > 30 minutes -Just before 1st anastomosis, bolus 3000-5000 U IV heparin and 1000 U / hour VEIN REPAIR -Attempt to anastomose 2 veins per artery -No tension; vein graft instead DISTAL REPLANTS -If replantations attempted at level of nail plate base, locating the dorsal veins usually not possible -possible indications: tip of dominant thumb, musician‘s fingertip -adequate venous drainage by 5 methods: (1) volar vein repair, (2) distal digital artery anastomosis to proximal vein, (3) leeches, (4) digital massage LEECHES -Leeches engorged in 15-30 minutes, then detach; bleed for 8-12 hours; when bleeding stops, leech re-applied. May need for 5-7 days. May infect with Aeromonas hydrophila (gram negative anaerobic rod); treat with debridement and antibiotic (aminoglycoside, tetracycline, Septra, or 3rd generation cephalosporin) VENOUS FLAPS -Cover veins; STSG, FTSG, local rotational skin flap, cross finger pedicle NERVE REPAIR -Align fascicles; epineurial repair (2-3 sutures) with 8-0 to 10-0 monofilament nylon -Nerve graft if primary repair not possible; medial antebrachial cutaneous nerve is ideal donor for digital nerve, located 1 fingerbreadth medial and 2 fingerbreadths distal to medial epicondyle, superficial to muscle fascia SKIN COVERAGE AND DRESSING -Meticulous hemostasis and loosely approximate skin with a few interrupted nylon sutures. Frequently midlateral digit incisions not closed; may need local flap or STSG. Fasciotomies done if any compression present. Cover wounds with xeroform and bulky dressing; all aspects being non-circumferential. Dorsal splint only; if flexor tendons repaired; volar only, if not. POST-OPERATIVE CARE -Elevate in foam rubber cradle boot -If arterial inflow diminished, then lower hand. If venous outflow slow, then elevate CHEMICAL ANTICOAGULATION (See Ch. 33) APM -If clean injury and anastomosis with brisk flow, then (1) aspirin 325 mg / day, (2) dipyridamole (50 mg TID), (3) dextran 40 (500cc / day). Consider (4) chlorpromazine (Thorazine) (25mg TID) – peripheral vasodilator and tranquilizer to diminish anxiety.

-If crush/avulsion injury, then heparin IV 1000 U / hr x 5-7 days for PTT = 1.5. If bloody dressing, then decrease dosage and change dressing to avoid ―blood cast‖ constriction. No heparin used if proximal to wrist. -To monitor replant, quantitative skin temperature measurement is most reliable. If temperature drops < 30 degrees C, then poor perfusion -Other methods to monitor: clinical—color, pulp turgor, capillary refill, warmth; see Ch. 33 -Patients room kept comfortably warm, no caffeine / smoking, bed rest 2-3 days. Antibiotics x 1 week PROCEDURES FOR DIFFICULT REPLANTS (children < 10 years old, crush / avulsion, poor flow) -IV heparin (see above) -#5 silicone ureteral stent placed adjacent to median or ulnar nerve (depends on digit) and continuous regional block with 5 cc bupivacaine (0.25 %) Q6-8 hours for sympathetic block for vasodilator. REVERSAL OF FAILING REPLANTS -Remove constricting dressings and sutures -Elevate or lower extremity (see above) -Heparin IV bolus (3000-5000 U) -Region block (stellate or brachial) if no indwelling catheter present and no anticoagulation given -Narcotics prn -Chlorpromazine to decrease anxiety and vasospasm -Hydrate -Maintain normal hematocrit -If need to re-explore (rare), do within 4-6 hours (No benefit if > 1-2 days) and possible reanastomose, remove thrombus, and / or vein graft MAJOR LIMB REPLANTS -Most are digit / hand level; if more proximal, muscle is issue: maximum cool avascular time is 10-12 hours. Will need extensive debridement to prevent infection and myonecrosis -Proximal replants need rapid arterial inflow. Consider Sundt and loop carotid endarterectomy shunts for 3-4 mm vessels and Ludenz peritoneal shunts for 2.5 – 3mm (Heyer Shulte Corp, Golenta, CA) to connect before bone fixation if > 4-6 hours. -Bones fixed with rigid plate/screws for long bones and crossed Steinmann pins at joint level -Arteries repaired before veins (to avoid systemic return of lactic acid and noxious metabolites) -Beneficial to give sodium bicarbonate IV before venous anastomosis -Extensive fasciotomies indicated in major limb replants -2 most common causes for failure in major limb replants: (1) myonecrosis with subsequent infection, (2) failure to provide adequate decompression of restored vessels -Cover exposed vessels with STSG -In digits, do not change dressing for 2 weeks for fear of vasospasm -In major limb replants, EUA in 48-72 hours to evaluated debride necrotic muscle

-No anticoagulants in major limb replants EXPECTATIONS WITH REPLANTS -80% viability rate -2 point discrimination in replanted thumbs: 11 mm, sharply amputated fingers 8mm; crush 15mm. -Recovery is better in children and with distal amputations -Cold intolerance present in most; usually improves with 2 years as sensibility recovers -PIP ROM 35 degrees for single digit proximal to FDS; 82 degrees distal to FDS -Appearance replanted part usually better than amp / revision or prosthesis -Best results: thumb, finger distal to FDS, wrist/distal forearm CHAPTER 35 – FREE SKIN AND COMPOSITE FLAPS (Jones, Lister) (a. = artery, n. = nerve, m. = muscle) Equivalent terms: Free flap = Microsurgical free flap = Microsurgical flap = Free tissue transfer FREE FLAP = Segment of skin, fascia, muscle, bone or composite combination that is detached from its donor site with immediate restoration of its blood supply by microvascular anastomosis of its inflow artery and outflow vein Axial-pattern flap – derives its circulation through inflow artery and outflow vein, termed a vascular pedicle GENERAL INDICATION FOR FLAP: (1) Defect with exposed joint cartilage or bone devoid of periosteum, or tendon devoid of paratenon that cannot support the neovascularization of a skin graft, (2) Any location where a skin graft might be subject to exposure and repeated ulceration ADVANTAGES OF FREE FLAPS: (1) Can cover large defects (local flaps are limited), (2) Do not compound injury to limb (as in local flap), (3) Permits elevation and mobilization (as opposed to distant pedicle flap like groin flap), (4) relatively unaffected by random movement by infant or disoriented patient CONTRAINDICATIONS – Limb with no potential for eventual function DEBRIDEMENT and 2nd looks needed. Clean wound is necessary for a flap. If wound not ready for flap after 72 hours, then chance of infection beneath flap rises 12-fold. Therefore consider split-thickness skin graft where possible and secondary flap reconstruction when wound healed. COMPLEX INJURY – 3 options: (1) primary amputation, (2) Radical debridement and emergency free flap, (3) Serial debridement and secondary free flap CLASSIFICATION

AXIAL PATTERN FLAP (may use 1 tissue or composite of skin, fascia, muscle, bone, tendon, nerve) CUTANEOUS FLAPS (vessel to skin alone) FLAP: DELTOID: ARTERY: Posterior circumflex humeral, COMPOSITE TISSUE: Axillary nerve FLAP: DORSALIS PEDIS: ARTERY: Anterior tibial-dorsalis pedis, COMPOSITE TISSUE: 2nd metatarsal, extensor tendons, superficial peroneal nerve FLAP: GROIN: ARTERY: Superficial and deep circumflex iliac arteries, COMPOSITE TISSUE: Iliac crest FLAP: SCAPULAR: ARTERY: Transverse branch of circumflex scapular artery, COMPOSITE TISSUE: Skin of dorsal back, Lateral border of scapula FLAP: PARASCAPULAR: ARTERY: Descending branch of circumflex scapular artery, COMPOSITE TISSUE: Skin of dorsal back, Lateral border of scapula FLAP: THIGH: ARTERY: Femoral and profunda femoris artery, COMPOSITE TISSUE: Medial and lateral cutaneous nerves of thigh FLAP: FIRST WEB SPACE-TOE PULP: ARTERY: Dorsalis pedis artery FASCIAL – FASCIOCUTANEOUS FLAPS FLAP: RADIAL FOREARM: ARTERY: Radial artery, COMPOSITE TISSUE: Radius bone, Palmaris longus tendon, Medial and lateral antebrachial cutaneous nerves FLAP: ULNAR FOREARM: ARTERY: Ulnar artery FLAP: POSTERIOR INTEROSSEOUS: ARTERY: Posterior interosseous artery, FLAP: ANTERIOR INTEROSSEOUS: ARTERY: Anterior interosseous artery FLAP: LATERAL ARM: ARTERY: Posterior radial artery, COMPOSITE TISSUE: Humerus bone, Triceps tendon, Posterior cutaneous nerve of arm FLAP: PERONEAL: ARTERY: Peroneal artery, COMPOSITE TISSUE: Fibula bone FLAP: PLANTAR: ARTERY: Medial plantar artery FLAP: SAPHENOUS: ARTERY: Saphenous artery from descending genicular artery, COMPOSITE TISSUE: Saphenous nerve FLAP: TEMPOROPARIETAL: ARTERY: Superficial temporal artery MUSCULOCUTANEOUS FLAPS FLAP: GRACILIS: ARTERY: Medial circumflex femoral artery FLAP: LATISSIMUS DORSI: ARTERY: Thoracodorsal artery FLAP: RECTUS ABDOMINUS: ARTERY: Deep inferior epigastric artery FLAP: RECTUS FEMORIS: ARTERY: Branch of profunda femoris artery FLAP: SERRATUS ANTERIOR: ARTERY: Thoracodorsal artery, COMPOSITE TISSUE: Rib bone, Latissimus dorsal skin VENOUS FLAPS – not widely used. Venous flaps for small hand defects. Arterialized venous flaps (2 types: AV fistula, or flow through)

PREOPERATIVE ASSESSMENT AND PREPARATION TISSUE DEFECT – Evaluate size, depth, and special needs. Old wound needs to be debrided to normal tissue, if possible. Because of scar contracture, flap needs to be larger than defect (important to avoid tension) VASCULAR STATUS – Palpate pulse and evaluate with Doppler pencil probe. If blood flow inadequate, consider interposition vein graft or ―flow through‖ flap. If unsure or old injury, consider noninvasive vascular studies and transfemoral angiography. Examine all potential flap donor sites – make sure no scars that may compromise flap; angiography not needed. Patient Preparation – Well perfused and warm. IVF to maintain urine output > 100 ml/hr and OR > 70 degrees. Consider 2 surgical teams: one to harvest flap, one to prepare recipient site. OPERATIVE TECHNIQUE WOUND DEBRIDEMENT – Defect should have flat bed. Retain all intact longitudinal vital structures (major vessels, nerves, tendons). Take tissue cultures after I & D. SKELETAL STABILIZATION – Need rigid fixation. If large defect with infection, consider antibiotic-impregnated methyl methacrylate spacer, followed by bone graft when clean (or 6 weeks after flap, if needed) SKIN PATTERN - Freshen skin edges and trace pattern of defect on glove wrapping paper. RECIPIENT VESSELS – Often need additional incision to expose recipient vessels. Avoid tight closure over vascular pedicle which may compromise flow – 3 techniques: (1) Tongue or ―pseudopod‖ of flap over vascular pedicle, (2) Split-thickness skin graft over pedicle, (3) Zigzag (at 60 degrees) incision over vessels, close with V-Y advancements. -Dissect vessels out preliminarily with loupes -Very important to find recipient vessels in area of normal tissue first! If start at wound, tendency is to stop too early -Recipient artery should be examined for: (1) large, expendable side braches to which end-to-end anastomosis could be performed, (2) atherosclerosis (hard, striations) PEDICLE LENGTH AND ACCESSIBILITY -Measure length of vascular pedicle required, from point of anastomosis to closest margin of defect -If selected flap does not have a long enough pedicle, then 3 solutions: (1) Choose different flap, (2) Harvest vein graft, (3) AV fistula using interposition vein graft between recipient artery and vein RAISING THE FLAP -Maximize pedicle length (so anastomosis far from wound and easier end-to-side anastomosis) -Start incision over 1 flap margin and find vessels. If anomalous or absent, can close. -Find plane to dissect, apply tension with skin hooks DISSECTION OF THE PEDICLE -Be extremely careful with pedicle. Unrecognized damage is a major cause of complication (poor perfusion / thrombosis) -Metal clips applied tightly. Bipolar away from main branch with smooth forceps between bipolar and main branch

-Bathe pedicle in 2% xylocaine or papaverine before dividing FLAP INSETTING -Suture flap into place, then anastomose with microscope. Drain (far from pedicle) DRESSINGS -No dressings over the flap (so it can be observed) -Antibacterial ointment and xeroform over incisions -To protect during sleep, cast with window: surgical glove turned inside out (to close fingers) packed with gauze sponges, laid over flap and cast, window cast at prominence

POST-OP CARE -Mobilize patient & extremity (non-casted portion) -1 APM: 40 cc bolus Dextran 40 just before clamp release, then Dextran 40 25 cc/hr x 5 days (70 kg adult) and ECASA 325 QD (Other APM: no meds) -Wound cleansing: H2O2, antibacterial ointment MONITOR -Flap check Q1 hour x 48 hours -Color – Look first at normal skin x 10 seconds, then the flap. Healthy flap is pale pink. If arterial inflow inadequate: paler with blue-gray tinge. If venous drainage poor: red, then purplered-blue. -CAPILLARY REFILL – If refill is slow and flap pale: arterial insufficiency. If refill swift and flap blue, then venous outflow problem -BLEEDING – Check only if suspicion of a problem. Flap and adjacent tissue punctured with 18-gauge needle to same depth. Healthy flap: bright red blood, same color as control, bleeds a little longer. Arterial inflow inadequate: no or brief bleeding. Venous outflow inadequate: dark red / purple blood, longer; persistent dark red bleeding from margins of a swollen flap. OTHER MONITORING TECHNIQUES -No standard method -1 APM: Hand-held Doppler probe Q 1 hour for flaps. Pulse oximeter for toe-to-hand transfers. Loss of arterial pulse = arterial occlusion; oxygen saturation < 85-90 = venous occlusion -other APM: photoplethysmography -Other techniques: (1) Differential surface temperature monitoring (difference > 1.8 degrees C at 2 points in time = arterial or venous occlusion), (2) Laser Doppler, (3) Implantable Doppler, (4) pH electrodes, (5) oxygen electrodes SAVING THE FAILING FLAP -Check and fix patient‘s general condition: hypotension, low circulating volume (low urine output), cardiopulmonary impairment, cold room. -Remove tight cast / dressings / sutures -Reposition extremity

-Look for hematoma (flap edematous and discolored, persistent serosanguinous ooze from margins). If suspected, then immediately remove a few sutures opposite the pedicle and take to O.R. to evacuate hematoma. EXPLORATION IN THE OPERATING ROOM -Initially, only open incision for access to pedicle (not whole flap – would be hard to replace) -Hematoma evacuated with warm irrigation and finger -Examine pedicle for kinks, occlusions, thrombosis. Occluded vein usually obvious (turgid portion next to collapsed portion). Arterial occlusion detected digitally by lack of pulse or with sterile Doppler. -Do not hesitate to clamp and open anastomosis to assess flow. 3 reasons for clot in patient with normal clotting: (1) Poor arterial inflow, (2) ―Run-off‖ through flap impeded, (3) Technically imperfect anastomosis -After revision, keep patient in O.R. to ensure no further thrombosis OTHER SALVAGE TECHNIQUES -No definitive techniques LEECHES (=Hirudo medicinalis) -Used to salvage failing replanted digits and flaps in cases of venous congestion -Success up to 60-70% -Therapeutic effect from continued bleeding from bite after detachment (they also consume blood 10x body weight) -Secrete several pharmacologic agents: (1) Hirudin, the most potent natural anticoagulant known (inhibits fibrin to fibrinogen conversion), (2) hyaluronidase, an anti-histamine, (3) vasodilator -Risks: (1) Infection (Aeromonas hydrophila, can cause necrotizing infection 7-20%), (2) blood loss needing transfusion.

THROMBOLYTIC AGENTS, etc. -Heparin, streptokinase, urokinase, t-PA APM: Best solution to salvage failing free flap is surgical re-exploration of anastomosis, but leeches and thrombolytic agents may be considered. INFECTION RX: Surgical irrigation and debridement, antibiotics. Elevate flap opposite the pedicle SPECIFIC FREE FLAPS LATERAL ARM FLAP -Ideal for upper extremity reconstruction: harvest from same limb with same tourniquet -Can be as small as 10 cm2 or as large as entire arm into forearm -Can include segment of humerus 10 cm long and 25% circumference -Can be divided along midline for contouring -Deficiencies: Very noticeable donor defect, may be bulky requiring defatting

ANATOMY – Arterial supply = posterior radial collateral artery (1 of 2 terminal branches of profunda brachii artery). Brachial artery to profunda brachii accompanies radial nerve in spiral groove until both penetrate lateral muscular septum just distal to deltoid insertion. Profunda brachii then divides to anterior radial collateral artery (that continues with radial nerve anterior to brachioradialis origin) and posterior radial collateral artery (that passes posterior to lateral intermuscular septum), lies close to bone, supplying bone, muscles (ant. & post.), fascia & skin; then anastomoses with olecranon anastomosis and radial recurrent artery branches. Flap may be extended 12 cm below lateral epicondyle. Artery accompanied by 2 venae comitantes and 2 nn. Posterior cutaneous n. of arm and forearm, branches of radial n. OPERATIVE TECHNIQUE -Sterile tourniquet high on arm. Mark skin from deltoid tubercle to lateral epicondyle; this defines the midline of the flap. Flap template laid, centered more distally for a longer pedicle. -Incise skin at posterior margin down to fascia, elevate superficial to fascia posteriorly until midline of triceps tendon seen. Incise fascia at midline of tendon and elevate fascia away from tendon / muscle (may need to suture fascia to skin). Stop at septum. -Anterior margin raised, dissecting right up against aponeurosis of extensor origin. Then apply upward traction on flap with non-dominant hand and elevate septum from humerus periosteum with knife or bipolar (cauterize periosteal and muscular branches) -Ligate vessels that pass forward with radial nerve (seen between brachialis and brachioradialis). Dissect as far proximally as needed to achieve pedicle length approximately 6 cm. 2 posterior cutaneous nn. encountered – dissect and save the deeper posterior cutaneous n. of forearm. Divide the more superficial posterior cutaneous nerve of arm high and use to innervate flap. -If need longer pedicle, consider splitting lateral / long heads of triceps. Do not release tourniquet. APM (metal ligatures on vv. , none on a.) -Divide pedicle as high as possible -Defect closed primarily if < 6-8 cm wide, o/w STSG -Complications: (1) forearm hypesthesia, (2) temporary radial nerve palsy SCAPULAR FLAP ANATOMY – Artery = cutaneous branch of circumflex scapular a. Circumflex is 1st branch off subscapular a. , 2 cm from origin of subscapular a. off axillary a. Circumflex passes posteriorly thru triangular space (long head triceps lateral, teres major inf., subscapular mediosuperior) cutaneous branch runs posterior between teres minor above and teres major below and turns sharply medially over lateral border of scapula and divides into 2, 1 running transversely superficial to teres minor and infraspinatus and the other descends obliquely and parallel to scapula lateral border. Flaps based on transverse branch = scapular flap. If based on descending branch = parascapular flap. Can also harvest lateral border of scapula as vascularized bone graft (i.e. simultaneous dorsal hand coverage and metacarpal graft). Can also combine with latissimus flap. OPERATIVE TECHNIQUE -Lateral position -Use sterile Doppler to draw transverse and descending braches.

Flap templated. Transverse flap can go as far medially as spine (& farther) and laterally over deltoid. Width limit is 10 cm (need to close primarily; poor site for skin graft) -Flap margin incised down to infraspinatus fascia and raised (medial to lateral for scapular flap, inferior to superior for parascaspular flap) -As triangular space is approached, cutaneous branch of circumflex scapular a. displayed by transilluminating flap. -Triangular space approached by splitting teres minor from major. Dissect with care, several large, short, fragile braches supply muscles and scapular – need to be ligated -Dissect into axilla. Locate thoracodorsal a. under latissimus and follow proximally to define T-bifurcation of subscapular a. into thoracodorsal and circumflex scapular a. 15 cm pedicle can be achieved. LATISSIMUS DORSI FLAP ANATOMY – Artery is thoracodorsal a. , continuation of subscapular a. after circumflex scapular a. Thoracodorsal a. gives branches to serratus anterior m. before reaching hilum of latissimus, 11 cm from axillary a. Usually splits to upper and lateral braches (allows for hemi lat flap) -Diameter (1-2.5 mm) of thoracodorsal a. and length of pedicle (11-16 cm) makes this flap popular. OPERATIVE TECHNIQUE -Lateral position -Inverted L-shaped incision, anterior border of latissimus located and everted. Find thoracodorsal pedicle at hilum (approx. at nipple line), trace proximally and ligate and divide branches to serratus and teres major, circumflex scapular a. -Template (more posterior gives more muscle, anterior less muscle and thinner flap). Flap margins incised, through muscle (with flap cautery) Muscle elevated off serratus anterior m., flap dissected anterior to posterior , ligating perforators. Swing flap superiorly and define pedicle (a. & 2 vv.), divide pedicle high proximally. -Close donor site primarily and drain THE TAILORED LATISSIMUS -Narrow flap based on lateral branch. Ligate upper branch. SERRATUS ANTERIOR MUSCLE FLAP -For small to moderate size defects -Reliable free muscle flap with consistent long vascular pedicle and large vessels with minimal donor morbidity ANATOMY – Serratus anterior muscle origin: 1st 9 ribs, insertion: medial scapular border. Dual vascular supply: Large branch of thoracodorsal a. to lower 3 slips from 7 through 9th ribs. Branches of lateral thoracic a. to upper 6 slips. If necessary, a long (15 cm) pedicle can be obtained by dissecting the thoracodorsal a. & v. all the way to its origin from the subscapular a. Serratus innervation: long thoracic n. branches to lower 3 slips can be dissected out and kept

with the flap to re-innervate it as a functional free muscle transfer (i.e. for thenar muscle reconstruction). Maintain upper 6 slips so no winging occurs. OPERATIVE TECHNIQUE -Lateral position. Long mid-axillary incision. Elevate anterior border of latissimus and retract to reveal thoracodorsal pedicle and serratus branch. Divide small vascular branches to upper 6 slips, but preserve ones to lower 3. Carefully divide n. branches to lower 3 slips form main branch of long thoracic n. From inferior to superior, divide 3 slips of serratus form 7-9 ribs and elevate off chest wall (do not penetrate pleura or intercostals mm.) Divide muscle off insertion to scapula. GROIN FLAP (cutaneous flap) ANATOMY – Artery: superficial circumflex iliac a. (present in 96%) arises from femoral a. at femoral triangle, passing over sartorius, goes laterally, parallel to and 2 cm below inguinal ligament. Maximum flap width: 12 cm. OPERATIVE TECHNIQUE – Draw midline axis of flap 2 cm inferior and parallel to inguinal ligament. Draw template. Inferior margin of flap incised through deep fascia to reveal sartorius and tensor fascia lata (laterally). Divide fascia in line with sartorius and identify superficial circumflex iliac a. in fascia as it is lifted from sartorius. Incise fascia as far as anterior superior iliac spine. Superior incision made to external oblique aponeurosis. Divide superficial inferior epigastric a. which passes superiorly. Raise flap by dissecting fascia off sartorius. Do not injure lateral cutaneous nerve to thigh. Dissect out and divide muscular branch to superficial circumflex iliac a. Dissect pedicle to femoral a. Veins are at medial border to long saphenous v. Primary closure. RADIAL FOREARM FLAP -Good for hand, most hands can be covered with radial forearm (non-free) flap (see Ch 58) -Need good ulnar a. and palmar arch flow -Radial a. dominant in 12% -Major drawback = skin grafted donor site -Loss of radial a. shown not to cause significant compromise ANATOMY – Artery: radial a. – origin: brachial a. (gives branches to fascia and skin of anterior and radiodorsal aspects of forearm, and also to radius allowing vascularized bone graft 10 cm long and 30%. Preop – perform Allen test. OPERATIVE TECHNIQUE -Map radial a. with Doppler and mark on skin. Mark v. Template with a. on radial border, usually at mid to distal forearm. Preferable to stay 3-5 cm proximal to wrist crease. Preserving cephalic v., branches of superficial radial n., and paratenon, incise deep fascia around flap and elevate beneath deep fascia (may suture fascia to skin). Identify radial a. and 2 venae comitantes, ligate and divide venae comitantes distally. Radial a. divided between ligature proximally and clamp distally. Raise flap from distal to proximal, dividing pedicle branches to deeper tissue, as far as brachial a. if necessary. -Deflate tourniquet, flap and hand should reperfuse. Remove clamp from radial a. stump to assess retrograde flow. If inadequate, then reconstruct with reverse cephalic or grater saphenous v. If adequate, then ligate radial a., divide pedicle proximally and transfer flap. -Cover tendons with mm. If possible, cover donor site with STSG.

TEMPOROPARIETAL FASCIA ANATOMY – Artery: superficial temporal a. (diameter 1.8 – 2.2 mm, pedicle length 4-5 cm) Fascia between scalp and temporalis fascia. OPERATIVE TECHNIQUE -Supine, head turned. Map superficial temporal a. with Doppler and template. 1 cm strip scalp shaved over a. Incise (may need L or T incision for larger flap), identify pedicle in front of ear. Scalp elevated between SQ and temporoparietal fascia – extend anteriorly and posteriorly (avoid injury to facial n. anteriorly) Incise superior and posterior margins of fascial flap and enter plane between temporoparietal and temporalis fascia. Incise anterior margin and divide frontal branch a. to forehead. Close primarily. Occasional complication: alopecia. NEUROVASCULAR FIRST WEB SPACE FLAPS (PARTIAL TOE TRANSFERS) -Used for reconstruction of digital pulp defects or crucial areas of the hand that require sensation -Can use single pulp, all or part of nail, and part of 2nd toe ANATOMY – Arteries: Lateral digital artery to great toe; medial digital artery to 2nd toe, both arise from variable ―arterial complex‖ with 2 sources: first dorsal metatarsal a. (FDMA) from the dorsalis pedis a. and the common plantar digital a. from the plantar arch. 2 sources of n. supply: lateral & medial plantar digital nn., deep peroneal n. dorsally. OPERATIVE TECHNIQUE -Doppler map FDMA. Map vv. – 2 systems: (1) Arch which drains into greater saphenous, (2) Veins over medial great toe. Incision needs to incorporate v. Template. -Incise distally 1st, dissect web space and identify arterial complex (may be as far as 1 cm proximally into web. Dissect into toes and proximally to fully display arterial complex. -Long pedicle is preferred (FDMA to dorsalis pedis) – dissect it proximally -Decide on anastomosis site in hand. For thumb, branch of radial a. just distal to anatomic snuffbox between 1st and 2nd metacarpal bases is best. In most patients, this pedicle distance correlates to point where FDMA arises from dorsalis pedis a. -If FDMA unsatisfactory, 2 choices: (1) use shorter common digital a., hoping pedicle is long enough, (2) use interposition graft. -Dissect and maintain deep peroneal n. with flap to be repaired to radial digital n. of thumb -Through plantar incision, identify and dissect lateral digital n. to repair to ulnar digital n. of thumb. -If only pulp flap, dissect flap right off bone -If nail plate incorporated, then harvest dorsal cortex of distal phalanx with coronal cut from the distal wound (avoid vascular injury) -Reperfuse flap to test be for ligating pedicle and transferring -STSG defect, walking cast (boot) CHAPTER 36 – FUNCTIONING FREE MUSCLE TRANSFERS (Manktelow, Anastakis) GENERAL PRINCIPLES

-Most common causes of muscle loss: (1) direct muscular trauma, (2) Volkmann‘s ischemic paralysis, (3) electrical burns, (4) post-replantation gas gangrene, (5) longstanding nerve injury, (6) muscular excision for tumor -If tendon transfer can give adequate result, it should be used instead of muscle transfer GUIDELINES FOR PATIENT SELECTION -Available, undamaged motor nerve, artery, and vein at the site of muscle transplantation -Adequate skin coverage for the distal half of the muscle -Supple joints and gliding tendons -Good hand sensibility and intrinsic function -Adequate antagonist muscle function -Good patient motivation -No simpler solution for the patient‘s problem -Most common replaced muscles: finger flexors. Others: finger extensors, biceps, triceps, deltoid -Most common donor: gracilis DONORS GRACILIS ANATOMY – Origin: pubis & ischial ramus. Insertion: medial shaft tibia below tibial tubercle. Belly is posterior to adductor longus & sartorius, distally tendon is posterior to sartorius and anterior to semitendinosus -2-3 pedicles: Proximal one is dominant, under adductor longus. Origin: profunda femoris a., 12 mm diameter, 6 cm long, enters muscle 8-12 cm from muscle origin. 2 venae comitantes (1-4 mm diameter) -1 motor nerve: branch of obturator, with 2-3 fascicles, enters muscle, just proximal to pedicle, lies under adductor -With nerve stimulator, usually can separate muscle into different neuromuscular territories, which is useful to provide independent thumb and finger flexion -No apparent deficit in leg function after gracilis harvest TECHNIQUE -Draw straight line between tendon of adductor longus and tibial tubercle (gracilis is posterior to this line) -For myocutaneous flap, incise 2 cm posterior to upper border of gracilis in proximal ½ of thigh. Dissect through fascia and separate gracilis from other muscles -Key landmark: palpable adductor longus tendon, which is retracted superiorly to expose neurovascular structures that enter gracilis on deep aspect of anterior margin -Dissect out pedicle (divide side branches to adductor magnus and longus). Divide secondary pedicles distally -Tendon is divided through transverse incision in distal thigh. Origin is then divided. Wait for recipient site to be ready before dividing pedicle. -If myocutaneous flap needed, then skin flap outlined over proximal muscle. Perforator is present opposite the dominant pedicle 15-20 cm distal to pubic tubercle.

LATISSIMUS DORSI (See Ch. 35) RECIPIENT -―Pure‖ motor nerves selected (1) For finger flexors: AIN, branches of median nerve to FDS, ulnar nerve branch to FDP, (2) For finger extensors: motor branch radial nerve, (3) For biceps: motor component musculocutaneous nerve (4) For deltoid: motor component axillary nerve, (5) For triceps: proximal branch radial nerve -Arteries: (1) Proximal forearm: small branches ulnar recurrent and anterior interosseous arteries for end-to-end anastomosis, (2) Radial and ulnar arteries for end-to-side anastomosis, (3) Palm: common digital arteries and palmar arch, (4) Dorsum hand: radial artery just proximal to 1st web space, (5) Upper arm: brachial or axillary artery end-to-side, thoracodorsal, anterior and posterior humeral circumflex, profunda brachial, branches of acromiothoracic -Veins: superficial or deep veins MUSCLE TRANSFER FOR FINGER FLEXION -If extensor intact, 1st consider ECRL transfer PREPARATION OF FOREARM – Identify and prepare vital structures: (1) ARTERY: radial or ulnar arteries or ulnar recurrent artery, or anterior interosseous artery, (2) VEIN: deep or superficial forearm vein, (3) NERVE: AIN preferred. Otherwise median nerve branch that innervated FDS or ulnar nerve branch to FDP, (4) TENDON ORIGIN: medial epicondyle and surrounding fascia, (5) TENDON INSERTION: FDP MUSCLE TRANSFER – TECHNIQUE -Before donor muscle is harvested, place on maximal stretch (for example, for gracilis, thigh abduction and knee extension) and mark every 5 cm -Position harvested muscle so nerve repair can be done as close as possible to the muscle -Suture the muscle origin to the medial epicondyle and stretch the insertion toward the hand to simulate motion and assure that vascular anastomosis will not be stretched -Perform microvascular anastomosis. Make sure vessel is normal. End-to-side repair is more reliable in zone of injury. 1 venous anastomosis if vein is larger than artery, 2 if not. Muscle should be pink and bleed 5 minutes after anastomosis, debride distal muscle that is not bleeding -Reinnervation: Since gracilis motor nerve is 60% fatty connective tissue, perform fascicular repair with 11-0 nylon. -Balance Tendons – FDP sutured together side-to-side so each digit is slightly more flexed than the adjacent radial digit. Suture the FPL tendon to the FDP with some slack so the fingers flex 1st. This will allow the thumb to ―key pinch‖ with the index finger. If the gracilis is split for independent movement, than deep FDP & FPL reconstructed separately. -Muscle tensioning: Fully extend wrist and fingers. Stretch muscle so markers are 5 cm apart. Mark FDP / FPL tendon to donor tendon and weave suture together. -STSG proximal donor muscles, skin flap distal ½ (tendinous) POST-OP -Splint in safety position

-If thromboses, re-anastomose within 4 hours, otherwise, will need another muscle graft. -Important to maintain good perfusion (IVF, monitor UOP) -Passive ROM / stretch at 2 weeks MUSCLE TRANSFER FOR FINGER EXTENSION -Consider tendon transfer if available -If combined flexor / extensor injuries, wrist must be stabilized, either with ECRL & ECU tenodesis to radius or wrist fusion -Gracilis muscle best donor PREPARATION FOREARM -Identify & prepare vital structures (1) ARTERY: radial artery end-to-side, or radial recurrent branch of radial artery. Route gracilis artery under or over mobile wad, (2) VEIN: superficial or deep forearm vein, (3) NERVE: PIN after supinator, (4) TENDON ORIGIN: Lateral epicondyle & surrounding fascia, (5) TENDON INSERTION: EDC & EPL. MUSCLE TRANSFER -Similar to flexor transfer (see above). Weave EDC together for equal extension. Re-route EPL: withdraw tendon at MP level and tunnel along radial aspect 1st metacarpal – traction should produce thumb extension & abduction. -Tension donor muscle and suture weave EDC. Weave EPL into this mass. Fingers should sit in position of function after repair. Splint 1-2 weeks, then P & AROM. CLINICAL EXPERIENCE – FOREARM MUSCLE TRANSFERS -Some need pre-transfer procedures for problems: (1) nerve loss (nerve repair or grafting), (2) joint contractures, (3) tendon adhesions -Some need secondary procedure: (1) tenotomy, (2) capsulotomy, (3) tenolysis, (4) tendon transfer, (5) digital fusion, (6) MP capsulodeses -RESULTS: >50% able to close fist, mean grip strength 38% normal, mean pinch strength 38% -2 major factors that worsen results: (1) intrinsic function absence, (2) supination/ pronation absence MUSCLE TRANSFER FOR BICEPS RECONSTRUCTION INDICATIONS – Patient lacked elbow flexion and local transfers (latissimus dorsi or pectoralis major) not available ARM PREPARATION – (1) ARTERY: Brachial artery or profunda brachii or humeral circumflex arteries or ulnar recurrent artery (2) VEIN: superficial or deep veins, (3) NERVE: motor portion of musculocutaneous nerve (4) TENDON ORIGIN: acromion and distal end clavicle (periosteum or bone anchors) (5) TENDON INSERTION: biceps tendon MUSCULOCUTANEOUS NERVE -50% is motor / 50% sensory -Usually 4 fascicles that need to be separated and tagged with fine

sutures -Identify motor braches that went to biceps and brachialis. If not possible, then awake nerve stimulation or histochemical staining to determine AWAKE NERVE STIMULATION -Under general anesthesia, dissect at fascicles. Then awaken patient & use nerve stimulator for each fascicle. Sensory fascicles produce burning discomfort localized to skin. Motor fascicles produce deeper aching sensation localized to muscle belly MUSCLE TRANSFER -Principles same as forearm (see above). Coapt gracilis nerve to motor fascicles of musculocutaneous nerve POST-OP -Elbow flexed in Velpeau dressing & sling x 3 weeks, then gentle P & AROM. RESULTS – 4/5 motor MUSCLE TRANSFER FOR TRICEPS RECONSTRUCTION -Principles similar to biceps. Tendon origin: lateral aspect of scapula near glenoid fossa. Insertion to triceps tendon or olecranon. Innervation - radial nerve branch. Artery – any available in area, possibly brachial artery and axillary vein. Results: 4/5 motor. MUSCLE TRANSFER FOR DELTOID RECONSTRUCTION Indications: -Patients with loss shoulder flexion and abduction; need flexion to position hand in front of body. However many patients will be able to flex using supraspinatus & secondary shoulder muscles. -Causes: muscle loss (trauma, tumor excision), late recognition axillary nerve injury PREPARATION OF ARM – (1) ARTERY: Thoracodorsal artery long pedicle can be developed, (2) VEINS: venae comitantes, (3) NERVE: motor portions of axillary nerve, (4) TENDON ORIGIN: Acromion and distal end clavicle, (5) TENDON INSERTION: deltoid tendon or humerus (through bony tunnel) -To identify axillary nerve, divide pectoralis major insertion 1 cm from humerus and do anterior approach to posterior cord and axillary nerve. Reattach pectoralis major after. MUSCLE TRANSFER – Follow principles POST-OP – Velpeau dressing / sling with elbow flexed x 3 weeks, then P & AROM CHAPTER 37 – VASCULARIZED BONE GRAFTING (Bishop) -Experimental studies have demonstrated ability of vascularized bone grafts to revascularize ischemic bone (Hori, JHS, ‗79) (Gonzalez, J Reconstr Microsurg, ‘90)

PEDICLE VS. FREE FLAP -FREE FLAP = Free transfer with microvascular anastomosis -PEDICLE GRAFT = Transfer without division of pedicle BIOLOGY OF CONVENTIONAL BONE GRAFTS -Bone graft incorporation is by ―creeping substitution‖ = a process of gradual vascular ingrowth, resorption, and replacement of necrotic bone -Cancellous bone has greater inductive capacity than cortical bone. -Allograft replacement is slower and less complete compared to autografts, and invokes a local and systemic immune response BIOLOGY OF VASCULARIZED BONE GRAFTS -Unlike conventional bone grafts, vascularized bone remains alive and dynamic; does not undergo creeping substitution, significant osteopenia not seen, has improved strength, healing, and stress response OTHER ADVANTAGES OF VASCULARIZED BONE GRAFTS -Option of restoring longitudinal growth by including growth plate -Can revascularize necrotic and/or non-united bone -Can improve blood flow to scarred soft-tissue beds -Can reconstruct composite tissue loss VASCULARIZED BONE GRAFT INDICATIONS -If bone defect is < 6 cm with well-vascularized bed, adequate soft tissue cover, no infection, then consider conventional non-vascularized bone graft -Otherwise, consider vascularized bone graft, specifically for: traumatic bone loss, tumor resection, osteomyelitis / infected non-union, non-union, congenital pseudarthrosis, poorly vascularized bone / bed scarring, infection, or irradiation, complex tissue loss, physeal arrest, AVN (i.e. femoral head, scaphoid, talus, lunate). Grafts have been shown to bring neovascularization and new bone formation. OSTEOMYELITIS -If history of infection, it is critical that sepsis is inactive before vascular bone grafting -Commonly used criteria used to determine inactive sepsis include: absence of sinus tracts, negative bacterial cultures, negative C-reactive protein, ESR < 15 mm/hr for 1 month VASCULARIZED GRAFTS FOR UPPER EXTREMITY BONE DEFECTS -Sources: fibula, iliac crest, distal radius, metacarpal, metatarsal, scapula, rib, pisiform, vascularized periosteum -Arteriography of recipient site frequently recommended, particularly when history of vascular damage -End-to-side arterial anastomosis may have higher patency rate -Graft may be placed ortho or retrograde (no difference) -Addition of cancellous graft at junctions increases primary healing rate

RECIPIENTS HUMERUS – Long spanning compression plate or plates at each end. If possible, place fibula intramedullarly. If not, add cancellous graft to ends. Shoulder spica cast post-op. End-to-side anastomosis to brachial artery and end-to-end to cephalic vein or brachial vena comitantes FOREARM – If massive both bones forearm loss, use dual fibular grafts or double-barrel graft, or 1 graft may be placed from proximal ulna to distal radius to create one-bone forearm. End-toside anastomoses to radial or ulnar artery, end-to-end anastomosis to venae comitantes of cephalic or basilic veins. LAC post-op. WRIST – For scaphoid fracture (proximal pole nonunion or AVN) and Kienbocks. Pedicle from radius, pisiform, ulna, or metacarpal. SPECIFIC VASCULARIZED GRAFTS: LONG BONE RECONSTRUCTION FIBULA ANATOMY -Long, straight segment 26-30 cm -Has single nutrient vessel (from peroneal artery) entering its middle 1/3 and anastomoses with periosteal vessels from the peroneal and anterior tibial arteries -Proximal epiphysis supplied by lateral inferior genicular vessels (needed for physeal growth) -Fasciocutaneous skin paddle (10 x 20 cm) possible by fasciocutaneous / myocutaneous perforators from peroneal artery which can be located by Doppler probe -Osteomuscular flaps may include FHL, portions of soleus or peroneals -Peroneal pedicle length 6-8 cm. Diameter of artery: 1.5 – 3 mm. Has 2 venae comitantes. TECHNIQUE OSSEOUS FIBULAR FREE FLAP -Supine, ipsilateral hip bumped up, knee flexed. Fibula measured and middle 1/3 identified. Incise along longitudinal axis laterally to expose peroneous longus; fat stripe posteriorly marks interval between soleus and peroneus longus. Bluntly dissect in this plane, reflect the soleus posteriorly and identify FHL. Dissect proximally, elevating soleus off fibula. Ligate branches from peroneal artery, unless obtaining composite with soleus. Carefully mobilize peroneal vessels. -Lateral compartment muscles elevated from fibula; proximally subperiosteally to avoid peroneal nerve injury which lies directly on fibular neck -Anterior compartment elevated, protecting deep branch peroneal nerve. Identify anterior tibial vessels and interosseous membrane. Either divide interosseous membrane first or fibula with Gigli saw. Entire proximal fibula may be harvested; distal 7 – 8 cm should remain to prevent valgus ankle instability. In children, distal tib-fib syndesmotic fusion with iliac crest interposition graft and syndesmotic screw -After interosseous membrane and bone divided, ligate peroneal artery distally. Dissect pedicle as for proximally as possible, to origin at posterior tibial artery and venae comitantes. OSTEOCUTANEOUS FLAP -Locate perforators with Doppler (usually near soleus-peroneal junction at lateral intermuscular septum). Peroneal-soleus interval

left undisturbed in mid and distal 1/3 until peroneal vessels exposed anteriorly. Divide posterior skin flap first and mobilize back to peroneal vessels. STSG. FIBULA WITH PHYSIS -Posterior approach proximally with transverse incision at popliteal fossa. Lateral inferior genicular vessel identified on either side of lateral head of gastrocnemius, followed to origin from popliteal vessel. Once vessels isolated, release fibular head, etc. -2 options for anastomosis: (1) end-to-side suture of genicular vessels to peroneal vessels and only 1 anastomosis needed at recipient site (2) 2 separate pedicles of recipient FIBULA WITH MUSCLE -May harvest lateral portion of soleus &/or FHL. Spare peroneal branches to muscles and divide muscles longitudinally with graft DOUBLE-BARREL FLAP -Use to graft both radius and ulna or to strengthen graft for femur -Osteotomize free fibular graft at mid-point, but preserve pedicle ILIAC CREST ANATOMY -Dual blood supply: (1) Deep circumflex iliac artery (DCIA), (2) Superficial circumflex iliac artery (SCIA). DCIA more important than SCIA. -Has musculocutaneous perforators (1 cm superior to iliac crest) allowing skin paddle 7 x 10 to 15 x 30 -DCIA arises from external iliac artery 1 cm superior to inguinal ligament, gives branches to internal oblique and iliacus muscles, courses cephalad and laterally toward ASIS between extraperitoneal fat and transversus muscle, pierces transversus muscle and runs between it and internal oblique along inner lip of iliac crest adjacent to iliacus muscle. Practical harvest limit of crest = 10 cm TECHNIQUE -Supine, ipsilateral hip bumped. Mark skin flap – axis: inner margin iliac crest, center 4 – 8 cm posterior to ASIS. Mark pubic tubercle, ASIS, femoral pulse, iliac crest -Incise medial skin flap obliquely inferiorly in line with femoral pulse. Just superior to inguinal ligament, incise external oblique, exposing inguinal canal contents, isolate them and retract medially with Penrose. -Floor of canal (internal oblique & transversalis fascia) incised to visualize DCIA and veins. Identify their origin and dissect back towards ASIS, ligating multiple branches (including large ascending branch). Spare lateral femoral cutaneous nerve if deep to vessels, otherwise transect and repair later. -Section external and internal oblique and transversus muscles 2 cm medial to iliac crest -Make lateral skin incision and dissect tensor fascia lata and gluteal vessels extraperiosteally from outer table ilium. Osteotomize ileum and divide pedicle

-Good closure is important to prevent hernia. Approximate transversalis to iliacus fascia, then internal and external oblique to gluteus and tensor fascia lata. Primary skin closure (flex hip) OTHER VASCULARIZED GRAFTS FOR LONG BONE RECONSTRUCTION (See Ch. 35) Experimental: vascularized periosteal grafts, manufactured bone grafts MONITORING BUOY FLAP – Most preferred is fasciocutaneous flap monitoring. Immediate operative exploration if loosening dressing, altering limb position, trial anticoagulation does not reverse changes in 1-2 hours OTHERS: Doppler, bone scan (before 1st week), arteriogram, serial x-rays RESULTS BY DONOR BONE: Fibula better than iliac crest (lower complications, higher eventual union: 82% vs. 67%). Most authors unsatisfied with skin flap in iliac crest BY LOCATION – Forearm with best results. Average time to union: 6 months BY DIAGNOSIS – Results with history of infection worse than other diagnoses (primary union 49% vs. 69%, overall union 77% vs. 84%). For congenital pseudarthrosis of tibia and forearm, vascularized bone graft superior to other techniques (bone graft, osteotomy, electrical stimulation) COMPLICATIONS IMPAIRED VASCULARITY – 10% vessel thrombosis with fibular grafts – need exploration (viability of failed vascular grafts worse than conventional bone grafts) DELAYED UNION: NEED FOR SECONDARY BONE GRAFT -Primary healing 68%, overall 80‘s% (achieved union after cancellous autograft at non-united junction +/- revision of fixation, after 67 month from primary surgery) STRESS FRACTURES – Not uncommon (23%) – usually through graft. If nondisplaced, cast. If displaced, internal vs. ex-fix +/- bone grafting DONOR SITES FIBULA – Transient peroneal nerve palsy, FHL contracture, stress fracture tibia, compartment syndrome. Mild persistent weakness / sensory loss ILIAC CREST – Hernias. Skin flap loss.

CARPAL VASCULARIZED BONE GRAFTS -Used to aid fracture healing, replace bone deficiency, aid in revascularizing ischemic bone. Examples: scaphoid fracture and pseudarthrosis, Kienbock‘s. SOURCES -Dorsal and palmar radius, pisiform, metacarpal head -Palmar radius grafts require dissection around important radiocarpal ligaments and have unpredictable nutrient arteries

INDICATIONS SCAPHOID NONUNION – Conventional grafts (Matti-Russe) may be contraindicated in the presence of avascular fragment (Green, JHS, ‘85) as evidenced by sclerosis of proximal pole on x-ray and MRI and absence of bleeding intra-op. Vascularized bone grafts may increase rate and frequency of healing. Specific indications: (1) displaced acute fractures with small proximal fragment or bone deficiency requiring grafting, (2) failed conventional grafts, (3) nonunion of proximal pole fractures, especially when associated with AVN KIENBOCK‘S DISEASE -RX controversial; large number of treatment options: joint leveling, revascularization, capitate shortening, intercarpal arthrodesis, lunate excision +/- replacement. Salvage for advanced OA: PRC or wrist arthrodesis -Vascularized grafts: excellent pain relief and improved ROM and strength. X-ray progression / collapse in 0-15%. X-ray and MRI evidence of revascularization seen. May be especially useful if ulna positive or neutral. VASCULARIZED GRAFTS FOR THE WRIST HARVEST OF DORSAL RADIUS GRAFTS ANATOMY -4 extraosseous vessels contribute nutrient vessels to the distal radius and ulna. Contributions from radial, ulnar, anterior and posterior interosseous arteries. They are described by their relationship (2 superficial and 2 deep) to the extensor compartments and retinaculum -1,2 intercompartmental supraretinacular arteries (1,2 ICSRA) – between 1st & 2nd dorsal compartments -2,3 intercompartmental supraretinacular arteries – between 2nd & 3rd dorsal compartments -2 deep vessels lie on the radius on the floor of the 4th and 5th dorsal compartments: 4th & 5th extensor compartment arteries (4th & 5th ECA) -1,2 ICSRA – originates from radial artery 5 cm proximal to radiocarpal joint, passes under BR to lie on dorsal surface retinaculum. Distally joins the radial artery and radiocarpal arch. Enters radius at tubercle between 1st and 2nd dorsal compartments. Has short arc of rotation. -2,3 ICSRA – originates proximally from anterior interosseous artery or its posterior division. Anastomoses with dorsal intercarpal arch and possibly with dorsal radiocarpal arch and 4th ECA. 1 large nutrient branch enters the radius at 2nd extensor compartment floor. Arc of rotation to entire proximal carpal row -4th ECA – Originates from posterior division of anterior interosseous artery or 5th ECA. Anastomoses with dorsal intercarpal and dorsal radiocarpal arch with connections to 2,3 ICSRA and 5th ECA. Lies in radial aspect of 4th compartment, adjacent to PIN. Occasionally lies in 3,4 septum -5th ECA – Similar origination and anastomoses as 4th ECA. Largest of dorsal vessels. On radial floor of 5th extensor compartment. Diameter approximately 0.5 mm. DISTAL ANASTOMOSES – with dorsal intercarpal arch, dorsal radiocarpal arch, dorsal supraretinacular arch 1,2 ICSRA GRAFT

-Originally described by Zaidemberg -Useful for most scaphoid non-unions but cannot be used for other carpal bones because of short arc of motion HARVEST TECHNIQUE -Elevate extremity and inflate tourniquet. Do not use Esmarch (makes vessel visualization difficult). Curvilinear dorsoradial incision. Superficial radial nerve protected. SQ tissues gently raised from retinaculum and 1,2 ICSRA and venae comitantes visualized on retinaculum. Dissect vessels distally toward radial artery in snuffbox. Vessel loop placed around distally based pedicle. Open 1st & 2nd dorsal compartment and maintain cuff of retinaculum with vessels at graft site, which should have its center 1.5 cm proximal to radiocarpal joint. SCAPHOID PREPARATION -Before graft out and elevated, transverse dorsal-radial capsulotomy made to expose non-union site. Curette fibrous tissue, osteotomies made for slot or wedge graft. Size and orientation of needed graft measured. GRAFT PLACEMENT FOR DORSAL INLAY GRAFT -Most cases where vascularized grafts used are for proximal pole nonunions, in which use of dorsal inlay graft is appropriate. Dorsal trough made with osteotomes, curettes, &/or burr and graft placed in with cortex dorsal. If proximal pole very small, then bone graft placed in it rather than fitted into dorsal slot. GRAFT PLACEMENT FOR INTERPOSITION (WEDGE) GRAFT -If scaphoid short with humpback deformity, the vascularized graft may be shaped as wedge graft with cortex palmar GRAFT ELEVATION -Ligate 1,2 ICSRA and veins proximal to graft protecting pedicle, cut graft with osteotomes. Once graft free, may release tourniquet to demonstrate bony bleeding, then re-inflate -Transpose graft beneath tendons and gently impact into position -Hold with screw or K-wires 2,3 ICSRA GRAFT -Similar principles as 1,2 ICSRA. Graft centered 13 mm proximal to radiocarpal joint. 2,3 ICSRA and venae comitantes seen on retinaculum on Lister‘s tubercle -Pedicle dissected distally to dorsal intercarpal arch (divide branches to dorsal radiocarpal arch). Open 2nd & 3rd dorsal compartment. Bone graft includes Lister‘s tubercle. 5+4 ECA GRAFT = Graft from 4 ECA‘s nutrient vessels, but blood flow from 5th ECA. (5th ECA without nutrient artery to bone) -Open 5th dorsal compartment, retract EDM, and identify 5th ECA on radial aspect of compartment or in septum. 5th ECA traced proximally to its origin from anterior interosseous artery. Divide branches to posterior interosseous artery and oblique dorsal artery to distal ulna. Proximal to DRUJ, identify 4th ECA origin. LUNATE PREPARATION

-Dorsal ligament-sparing capsulotomy made to expose lunate (―L‖-shaped with apex proximal radial). Inspect lunate; if not fragmented, then vascularized bone grafting feasible. Remove necrotic bone through dorsal opening (may need fluoroscopy); protect SL & LTq ligaments, leave shell of intact cartilage and subchondral bone. If collapsed, gently expand lunate with small elevator. BONE GRAFT ELEVATION AND PLACEMENT -5th ECA ligated at its proximal origin, making sure branch to 4th ECA preserved in pedicle. -Retracting EDC radially, bone graft (off of 4th ECA‘s nutrient vessels which enter 11 mm proximal to radiocarpal joint) osteotomized and raised. -Graft placed into lunate. No fixation required. JOINT UNLOADING FOR KIENBOCK‘S -Lunate must be unloaded post-op. Options‖ (1) ex-fix x 6 weeks, (2) intercarpal joint pinning x 3 months (ROM at 3 weeks), (3) capitate shortening, (4) intercarpal fusion RESULTS SCAPHOID -Zaidemberg, JHS ‘91, success in 11 patients -Bishop (at Mayo). 15/15 healed (ave. union 11 weeks) KIENBOCK‘S -Bochud, JHS ‘94: 43% good-excellent results, 43% fair, 14% poor CHAPTER 38 – VASCULARIZED JOINT TRANSFERS (Foucher) -3 main levels: PIP, MCP, CMC -Useful ROM for 11 ADL‘s: MCP 61, PIP 60, DIP 39 degrees -Treatment choices for damaged joints: amputation, fusion, prostheses, spacer, nonvascularized joint transfer, vascularized joint transfer (free or island) HISTORY OF OSTEOCHONDRAL JOINT TRANSPLANTATION -3 major categories of biological joint replacements: perichondrial joint grafts, allografts, autograft (vascularized or non-vascularized half or whole joint transfers) -Perichondrial Joint Grafts – results unpredictable -Allografts – Least successful method. Most cells (bone & cartilage) die. Transplants function for 6-8 months, then degenerative changes progress to complete joint disintegration -Autografts (non-vascularized) – limited survival of cartilage and controversial results of growth VASCULARIZED JOINT TRANSFER -Choices: heterodigital, island, or free transfer. Homodigital DIP to PIP transfer HETERODIGITAL ISLAND JOINT TRANSFER -Recipient prepared: debride skin, extensor and intrinsic tendons, cut bone. Do not violate flexor sheath

-Donor finger: dorsal skin flap with 2-3 dorsal veins, dissect 1 digital artery and nerve (nerve not absolute necessity). Need enough extensor tendon to overlap. Cut bone: length of intercalated segment is shorter than recipient defect to avoid flexion contracture if flexor tension increased. -Joint transferred (with attached pedicle) to recipient site and stabilized with K-wires or interosseous wires. Reattach flexor sheath and repair extensor tendon by overlapping. -Donor finger: arthrodesed, shortened, or ray amputation FREE HETERODIGITAL TRANSFER -Same as above, except must anatomose artery and vein(s) TRANSFERS IN THE SAME FINGER (HOMODIGITAL DIP to PIP TRANSFERS) -Similar to above island transfer -TECHNIQUE: Lateral incision from DIP to web on side of pedicle. 3 transverse incisions: 2 to isolate a dorsal skin flap over the DIP and 1 at the PIP to fit the transfer. Cut the extensor tendon, save 2+ dorsal veins. Sever 1 digital artery distally at level of osteotomy. Bone cuts made avoiding nail matrix distally and volar plate proximally. -Island transferred to PIP -Distally, arthrodesis performed with FDP re-insertion FREE VASCULARIZED TOE JOINT TRANSFER -2 types of toe joint available: PIP and MTP of 2nd and 3rd toe INDICATIONS: -If need joint reconstruction with possibility of growth in young patients -Allows compound transfers (bone, tendon, skin) -Authors have 20 year f/u demonstrating clinical durability and persistence of cartilage space -In adults heterodigital transfers with better ROM (50-80 degrees) than toe PIP to finger PIP (30‘s); so not good for adults; but consider in young growing patients with multiple PIP involvement and large complex loss (mean ROM 58 degrees). Same idea with MCP‘s SPECIFIC TRANSFERS TOE PIP JOINT RECONSTRUCTION (APM): -Use 2nd toe; ray is amputated -Toe dissected 1st through dorsal approach: ray resected with ―v‖ shaped incision with base at web and apex at mid-metatarsal dorsally and short ―v‖ plantarly. Extend dorsal incision longitudinally. -Dissect dorsal vein(s) to greater saphenous vein, and dissect dorsalis pedis artery beneath the EHL; dissect to the 1st web and identify the dorsal metatarsal artery, superficial to the intermetatarsal artery, superficial to the intermetatarsal ligament. If the diameter is insufficient, then osteotomize the base of the 2nd MT for exposure. May need to take 2 or 3 arteries in continuity with dorsalis pedis artery. -Longitudinally split the skin of the flap on the plantar-medial aspect, reflect the 2 flaps and open the flexor sheath and remove the flexor tendons. -Osteotomize the proximal and middle phalanges at the appropriate length; harvest bone pegs from the metatarsal for bone stabilization at either end. -Prepare the hand through a dorsal longitudinal incision; excise scar tissue

-Separate approach (ideally horizontal) to the 1st intermetacarpal space and radial artery and cephalic vein dissected out. SQ tunnel made to connect. -Trim toe phalanges to allow IM penetration. Transfer joint and fix with buried IM and oblique K-wires, single longitudinal K-wire in young patients. -Flexor sheath repaired, extensor brevis sutured to hand intrinsics; extensor longus to hand extrinsic extensor tendon. Artery anastomosed to radial artery; vein to cephalic vein. -Foot: ray amp closed. Exception: if IMA > 20 degrees then reconstruct 2nd toe (to avoid HV) OTHER TRANSFERS DOUBLE TRANSFER OF MTP & PIP (TOE) JOINTS TO ADJACENT MCP JOINTS -When 2 adjacent MCP joints need be reconstructed, then consider harvesting MTP & PIP from 2nd toe. MTP vessel: 2nd plantar metatarsal artery. PIP vessel: 1st dorsal (or plantar) artery TRANSFER OF ADJACENT PIP JOINT (TOE) TO ADJACENT PIP JOINTS OF THE HAND -To reconstruct 2 PIP‘s, harvest PIP‘s from 2nd and 3rd toes on separate pedicles. 2nd toe PIP pedicle: 1st plantar or dorsal metatarsal artery. 3rd toe PIP pedicle: 2nd plantar metatarsal artery -Amputate the 2nd ray and use part of the 2nd metatarsal for 3rd toe reconstruction

2ND TOE MTP JOINT TO THUMB CMC -For congenital thumb ray hypoplasia when CMC is missing and parents refuse pollicization (the best choice) TWISTED 2 TOE TRANSFER -Combine hallux and 2nd toe RESULTS -MP mean total active motion 35 degrees with extensor lag 45 degrees -PIP mean total active motion 22 degrees with extensor lag 55 degrees -In children, growth plates persist and no radiologic deterioration CHAPTER 39 – MICRONEURAL RECONSTRUCTION OF THE BRACHIAL PLEXIS (Hentz, James) (also see Ch. 51) -Hanno Millesi of Vienna, Austria: considered by many to be the father of microneurosurgical reconstruction -Full recovery after brachial plexus remains unachievable TYPES OF INJURY -Root avulsion =supraganglionic -Rupture=infraganglionic -Neuroma-in-continuity

PATHOLOGY OF THE TRACTION INJURY -Essentially all brachial plexus birth palsies and most traumatic brachial plexus injuries are due to traction -The typical candidate for microneural reconstruction is a young man who is thrown from his motorcycle, his shoulder is driven down and posterior and his neck driven in the opposite direction -Supporting tissues anchoring C5 & 6 roots to vertebral foramina are stronger than at C8 & T1 level, so C8 & T1 roots are more likely to be avulsed from the spinal cord where C5 & 6 roots are more likely to be stretched or rupture in continuity -75% of traumatic brachial plexus injuries have associated head injury, thoracic trauma, C-spine, or upper extremity fracture/dislocation; 20% have vascular trauma EVALUATION OF THE PATIENT HISTORY -Know the mechanism SPECIAL PHYSICAL SIGNS -HORNER‘S SYNDROME = ptosis, miosis (constriction of pupil), anhidrosis of the eye on affected side caused by paralysis of cervical sympathetic nerves and is associated with avulsion of C8 & T1 roots. Preganglionic sympathetic fibers are carried from the spinal cord with those roots. Poor prognostic sign for spontaneous recovery. May be present immediately or appear in 3-4 days. -SEVERE PAIN IN AN ANESTHETIC LIMB indicates deafferentation and is strongly correlated with root avulsion and poor prognosis -SHIFT OF HEAD AWAY FROM INJURED SIDE is evidence of denervation of paraspinous muscle and is associated with root avulsion. -Fractures of clavicle, cervical transverse processes, winged scapula, scapulothoracic dissociation, dislocation of AC or SC joints NEUROLOGIC EXAMINATION -Test functional groups; use chart to document (i.e. by Merle d‘Aubigne) -Rhomboids and serratus anterior are innervated by dorsal scapular and long thoracic nerves, which originate from roots; paralysis is associated with root avulsion of C5-7 -C5 arm elevation; C6 elbow flexion; C7 elbow extension, wrist flexion, finger extension (―7‖ sign); C8 fist; T1 open hand -Sensation tested by sharp-dull discrimination RADIOGRAPHY -X-rays of C-spine, chest, shoulder, humerus -CXR: AP inspiration and expiration to view diaphragm activity; a paralyzed diaphragm is an indicator of severe injury to upper plexus roots IMAGING STUDIES FOR PLEXUS INJURES: CT, MRI, MYELOGRAPHY (wait 1 month) -Traditional myelography has been mainly supplanted by CT and MRI, +/- contrast

-CT myelography gives good visualization of traumatic meningoceles (=pseudomeningoceles) which are usually, but not always associated with root avulsion -However, it is invasive and requires general anesthesia an infant -MRI T2-weighted highlight water and can show pseudomeningoceles. T1-weighted show roots and may show empty root sleeves and shift of spinal cord away from midline. Coronal reconstruction views are helpful -FSE-MRI (fast spin echo) may be helpful for infants since can do under sedation (not general anesthesia) and are faster than standard MRI -No gold standard for diagnosis of root avulsions SENSORY AND MOTOR EVOKED POTENTIALS -Perform sensory and motor evoked potentials testing after Wallerian degeneration period (1 month) -For example, sensory evoked potentials may show the ulnar nerve conducting an action potential despite ulnar anesthesia and 0/5 motor. This is strong evidence of preganglionic (usually root avulsion) injury, since sensory axons are still connected to the dorsal root ganglion cell bodies and haven‘t undergone Wallerian degeneration, but are disconnected from the spinal cord -EMG with fibrillation if denervated muscle INDICATIONS FOR SURGERY -Surgical exploration warranted when strong suspicion of root avulsion and nerve rupture -Exploration seldom results in any worsening -Even when total extremity palsy exists, < 20% have all 5 roots avulsed, therefore there is usually at least 1 root to repair or graft. -Also may perform neurotization CONTROVERSIAL INDICATIONS -Partial C8 and complete T1 lesion with some finger flexors working but intrinsic palsy and anesthesia in C8 and/or T1; C8 & T1 likely to be avulsed and irreparable: surgical reconstruction unlikely to recover intrinsics. If pain not disabling, perform tendon transfers. If >15 years and pain disabling, then explore an attempt reconstruction; may help pain CONTRAINDICATIONS ->1 year since injury (adult) -Advanced patient age >40 (relative contraindication) TIMING OF SURGERY IMMEDIATE SURGERY -Indicated for penetrating injury such as stab; or iatrogenic injury such as during TOS surgery -For traumatic traction injuries, APM is to wait 6-8 weeks. This allows: (1) further diagnostic tests, (2) permits the patient to experience effects of injury. Patient who has lived with a flail limb may better accept the ultimate functional limitations of microneural reconstruction -If spontaneous recovery occurs, continue observation; unless distal muscles recover in the absence of proximal muscle recovery ( indication for early exploration

EARLY SURGERY (6 weeks – 3 months; don‘t wait >6 months ( worse results) -Indicated if total or near total palsy, associated with high energy, and GSWs -If partial upper-level palsy or low energy mechanism, wait 3-6 months and operate when recovery plateaus. This allows in-continuity stretch lesions reasonable time to spontaneously regenerate -Key to decision-making is careful exams and recording by same observer -Presence or absence of advancing Tinel is a useful guide, i.e. no Tinel in the supraclavicular space in complete C5, 6 palsy is a poor sign for spontaneous recovery (probable root avulsion) and warrants early exploration OPERATIVE TECHNIQUE PATIENT PREPARATION AND INFORMED CONSENT -Patient and family must know expected outcome, length and risk of surgery and reinnervation -Home therapy program to maintain PROM -Autologous blood (1 unit) donation (especially if previous subclavian artery reconstruction) PATIENT AND MICROSCOPE POSITIONING -Electrodes for intra-operative corticosensory evoked potentials placed pre-op -Discuss with anesthesiologist length of procedure, need for intra-operative stimulation and recordings (avoid long-acting paralytic agents and ones that depress cortical response). Reposition head periodically to avoid scalp ischemia and hair loss -Patient supine with head on circular roll; roll under scapula, head rotated away from lesion and neck extended (not maximal). Drape arm free and support on arm board. ETT brought over center of forehead and profile kept low. -Well-padded tourniquets placed on both thighs; drape both legs free. 2nd team available to harvest sural nerve grafts -Microscope with long arm positioned at head of table on side opposite the lesion SURAL NERVE GRAFT HARVEST (See Ch. 43) -Longitudinal incision over the nerve to harvest it and its peroneally derived branch (adult: up to 35 cm in each leg) -Distal portion harvested with hip flexed and internally rotated; proximal portion with leg elevated -Wounds rapidly closed with staples

INCISIONS AND SURGICAL DISSECTION -Infiltrate skin with 1:200,000 epinephrine -Incise with superior-limb parallel to posterior order of SCM to the clavicle, then parallel to clavicle; cross clavicle to the coracoid, slightly zigzagged over the deltopectoral groove into the axillary fold, down medial arm -Split the platysma, avoid the external jugular vein -Elevate the platysma to expose SCM fibers and roll the SCM medially to expose the superficial layer of the deep cervical fascia

-Visualize the cervical plexus rami as they exit the fascia along the posterior border of the SCM -Open the superficial layer of the deep cervical fascia to encounter the cervical fat pad and omohyoid muscle -Divide the omohyoid between ties and push the fat pad medially and inferiorly -Identify the transverse cervical artery and its venae comitantes and ligate and divide them -Open the deep layer of the deep cervical fascia to expose the anterior and middle scalene muscles; place an angled laminectomy-type self-retaining retractor -In a patient without traction injury, the superior trunk of the plexus and suprascapular nerve are seen. If traction injury, superior trunk difficult to locate because of scar tissue, fibrotic scalenes -The phrenic nerve can help locate the C5 root. It lies on and parallel to the anterior scalene muscle; a nerve stimulator can help locate. It receives contributions from the C5 root, so the phrenic nerve should lead to the C5 root -Another landmark is the large cervical rami; traced proximally should lead to the C4 or C5 root -Transverse cervical artery may run over the C7 root -C8 is slightly above or at clavicle level -T1 just posterior to subclavian artery -Seldom necessary to osteotomize the clavicle; bluntly finger dissect under the clavicle and continue dissection inferior to it and mobilize the lateral border of the pectoralis major off the clavicle. Subclavius muscle divided and ends tagged -Finger penetrates clavipectoral fascia, wrap around clavicle, place gauze or umbilical tape around clavicle to retract it -If upper roots avulsed, rootlets and swollen dorsal root ganglion may be found behind clavicle or around C8 root -Any combination of injuries (avulsion, rupture, neuroma-in-continuity) may be found. May also have avulsion of axillary or musculocutaneous nerves, etc. Explore distally -Open deltopectoral groove, open clavipectoral fascia and partially release pectoralis major insertion -Identify pectoralis minor insertion on the coracoid, and develop its separation from the coracobrachialis and isolate the pectoralis minor with the finger—tag and divide it -Deep to it will be the lateral cord and subclavian-axillary artery. Dissect rest of distal plexus -Other landmarks: subscapular trunk off the axillary artery which helps locate the posterior cord; posterior circumflex humeral artery helps identify the axillary nerve -Put different color vessel loops around different structures and mark on a sterilized drawing of the normal plexus the operative findings and reconstructive plan

INTRA-OPERATIVE EVOKED POTENTIALS -After plexus dissected, intraoperative corticosensory evoked potential studies done on nerve roots to determine if they are in continuity with spinal cord. Root placed on electrodes and either 64, 128, or 256 stimulations done and averaged; this helps differentiate between avulsion and rupture -If neuroma-in-continuity, perform orthodromic and antidromic evoked potentials (most reliable after 2-3 months). If no or small response above background noise, then insufficient number of axons, and neuroma and adjacent damaged

nerve is resected and defect is grafted. If clear signal above background noise, then neurolysis performed INTRAOPERATIVE DECISIONS AND PRIORITIES OF REPAIR Priorities: (1) Elbow flexion by biceps/brachialis reinnervation, (2) Shoulder stabilization, abduction, external rotation by suprascapular nerve reinnervation, (3) Brachiothoracic pinch (adduction of arm against chest) by pectoralis major reinnervation, (4) Sensation below elbow in C6-7 region by lateral cord reinnervation, (5) Wrist extension and finger flexion by lateral and posterior cord reinnervation SURGICAL TECHNIQUES FOR PLEXOPLEXAL NERVE RECONSTRUCTION -Debride nerves in 1 mm increments until consistency and color of nerve is normal or as long as each cut looks better than it s precursor -Estimate number of nerve graft strands needed to cover the proximal components (a robust C5 or 6 root may need as many as 6 strands; smaller ones may need only 1-2) -Next, determine target nerves (map is helpful). Target nerves are usually suprascapular nerve and lateral and posterior cords. There are usually more targets than proximal sources TYPES OF NERVE GRAFTS CONVENTIONAL (NONVASCULARIZED) NERVE GRAFTS -Nerve grafts almost always needed; sural nerves are usual graft -Other potential donors: medial brachial, medial and lateral antebrachial cutaneous nerves, dorsal sensory branch of radial nerve VASCULARIZED NERVE GRAFTS -Indications are controversial -May be useful if graft bed poorly vascularized (shotgun wound or irradiation injury) -―One definite indication‖ is when gap > 6cm (long vascularized grafts work better: Chuang, JHS, 1993) -If C8 and T1 roots avulsed, then ulnar nerve is a good donor, based off of a brachial artery branch, usually superior ulnar collateral artery (either as pedicle graft or free transfer). Also ulnar nerve in forearm based off of ulnar artery can be used -Ideal recipient vessel is transverse scapular artery. Its vein is usually too large; but there are plenty of appropriate sized veins in the neck -Proximal end, then distal end repaired; vascular anastomosed last -Other donor nerves; ipsilateral dorsal sensory branch of radial nerve, sural, anterior tibial, superficial peroneal, saphenous GRAFTING METHODS -Fascicular nerve graft suturing technique (see ch. 43) -Patient donates blood; blood bank removes fibrinogen; use this to glue fascicles together -Measure and pre-cut nerve graft segments. Increase length by 15% to allow for shrinkage -Begin with supraclavicular neurorrhaphies (9-0 nylon usually used) with most caudad root or trunk and work in cephalad direction. Posterior before anterior. -Thread graft end through a large bore catheter CLOSURE

-Repair subclavian and omohyoid. Replace fat pad. Drain away from grafts. Repair pectoralis minor, clavipectoral fascia, and platysma SURGICAL TECHNIQUE FOR NERVE TRANSFER (NEUROTIZATION=extraplexal motor and sensory axons directed to distal plexal elements) -Option when all or almost all roots are avulsed resulting in totally flail, anesthetic limb -Nerves that may be transferred: spinal accessory nerve (CN XI=SAN), intercostal nerves (ICNs), phrenic nerve, supraclavicular nerve, motor branches of cervical rami. Others: medial pectoral nerves, cross-chest grafts -Most commonly used sources: SAN, ICNs from C3-6. No donors shown to be superior; outcome depends more on if nerve graft was needed to span the transfer (worse results) -Targets: suprascapular nerve (shoulder abduction and external rotation), musculocutaneous nerve (elbow flexion), lateral pectoral nerve (brachiothoracic pinch) -If all roots avulsed, then SAN to suprascapular nerve, 2-3 ICNs to musculocutaneous nerve, 1-2 ICNs to lateral pectoral nerve (all usually without grafts). Cervical plexus to median nerve portion of lateral cord with grafts (some authors don‘t like using SAN because of possible trapezial effect) -If C5 root remains, direct to suprascapular nerve with a graft and SAN to musculocutaneous nerve a ICNs to posterior cord -SAN is between SCM and trapezius and is dissected distally until joined by accessory C2 & 3 branches which must be spared to avoid total trapezial denervation. Before dividing SAN, verify its identity with a nerve stimulator -ICNs exposed through an oblique incision starting where initial incision enters the axillary fold. Inferior muscles cut from the rib, the NV bundle is on inferior side of rib; dissect nerve from vessels NERVE TRANSFFER IN NEGLECTED PLEXUS INJURES -For adults > 1 year (definitely 2 years) after plexus injury -Use combination of extraplexal nerve sources and free muscle transfer: for elbow flexion, innervate a free gracilis transfer with 2-3 ICNs (without nerve grafts). Proximal gracilis anchored to coracoid and distal woven into biceps (see ch. 36). Recipient artery is circumflex humeral or profunda brachii. If elbow flexion achieved, then glenohumeral fusion later. Then shouldercontrolled terminal prosthesis fitted -Other RX choice is amputation and complex prosthesis POST-OPERATIVE CARE AND FOLLOW-UP -Soft collar, shoulder immobilized in adduction, elbow 90 degrees. Sandbags on either side of head until awake and at night x 2 weeks, then unrestricted ROM -Assess nerve regeneration Q3 months. Return of function begins at 6 months, and continues for 2-3 years MICRONEURAL RECONSTRUCTION FOR BRACHIAL PLEXUS BIRTH PALSY -Mechanism of injury: excessive traction during difficult delivery -Risk factors: shoulder dystocia, cephalopelvic disproportion, high birth weight (>4000 g), maternal diabetes, forceps/suction delivery -Majority of lesions involve C5 & 6 and spare the hand

EVALUATION -Observe posture. Flail limb indicative of complete palsy; shoulder internally rotated, adducted, elbow extended, forearm pronated, wrist flexed indicates upper root palsy -Motor difficult to assess: stimulate movement and palpate muscle. Gilbert‘s modified MRI grading: M0 = no contraction, M1 = contraction without movement, M2 = slight movement without gravity, M3 = movement against gravity -Sensory exam: pinch skin and watch reaction -Trophic changes: hair growth, color -Horner‘s syndrome -DDX: clavicle fracture (get x-ray), separation of proximal humeral physis or GH septic joint (ultrasound for both) -EMGs not helpful -Re-examine in 1 month. 3 possibilities: (1) All muscles are recovering. Continue to observe, (2) Palsy is still complete and also with Horner‘s. Recommend plexus exploration and reconstruction at 2 months of age, (3) Hand is recovering, but no biceps/shoulder function. Reevaluate at 3 months. If any biceps return at 3 months, then continue to observe. If not, then get EMG and MRI. Total absence of electrical evidence of muscle reinnervation indicates root avulsion. MRI may show pseudomeningoceles. If still no biceps function at 6 months, then recommend plexus exploration and reconstruction PREOPERATIVE PREPARATION -Through discussion with family -Preop consult with occupational therapist to make a thermoplastic ―clamshell‖ to immobilize the head, shoulder, and chest post-op SURGICAL APPROACH -Similar to adults; usually see more roots from supraclavicular approach. Neuroma-in-continuity far more common in infants than adults. -If nerve grafting from supra to infraclavicular, then clavicle is sectioned obliquely after drill holes made on either side; repair with suture at end SURGICAL DECISION-MAKING -Results of neurolysis for neuromas are disappointing; therefore neuromas should be resected and nerves grafted -If roots are avulsed and confirmed by electrical studies, then reconstruct or neurotize. If surgical exam and electrical studies disagree, then leave and await spontaneous recovery -In infants, avulsion of all 5 roots has not been observed -Most commonly avulsed roots are C8 & T1. C6 & 7 avulsed in severe cases. C5 not usually avulsed POST-OP -Immobilized in custom thermoplastic clamshell x 3 weeks, then ROM, especially to prevent shoulder internal rotation contracture -Follow-up Q 3 months; biceps contraction by 5-6 months is good prognostic sign

-May need later tendon transfers RESULTS -Gilbert, Hand Clin, 1995: 436 plexus repairs: C5-6 palsy – 52% with good-excellent, 40% fair, 8% poor. If nerve transfers, 50% fairgood. 2/3 operated group achieved better functional result than their predicted nonoperative outcome base on natural history studies CHAPTER 40 – TOE-TO-THUMB TRANSPLANTATION (Gordon) -Replant when able; otherwise consider transplant -Goal of thumb reconstruction: restore pinch and grasp by creating thumb of ideal length and appearance with maximum strength, stability, movement, and sensation -Replant has potential for growth; important for children -May use great toe or 2nd toe; great toe is 20% larger than thumb. May decrease size (see below) INDICATIONS ETIOLOGY OF THE DEFECT TRAUMATIC DEFECTS -Most common indication -Know history; i.e. infection history, etc. -Examine for proximal injury TUMORS CONGENITAL DEFECTS -Most are best reconstructed by pollicization of index finger (see ch. 66), especially if > 3 digits present -If no digit available, consider transplant -Examples: hypoplasia, aplasia, symbrachydactyly, constriction ring syndrome, true transverse arrest -Structures (vessels, tendons) may be abnormal, unreconstructable; therefore, hand should be dissected 1st to assure adequate structures before donor tissue harvested -Viable growth plate enables 85% growth -Toe transplantation can be done if > 1year old; best if before 18 months since children have not yet established hand use patterns and incorporate the reconstructed thumb better -2 factors influence success: (1) mobile CMC, (2) bilateral -2nd toe preferred in children (better cosmetically, donor growth/gait better) CONSIDERATIONS IN THE HAND GENERAL FACTORS 3 QUESTIONS -Is toe transplant the best method of reconstruction? Consider other methods of reconstruction (see ch. 66) -Timing? Should usually wait until the patient is stabilized, physically and emotionally; and after full discussion done. Exception: acute injury where partial toe transplant will avoid further thumb loss

-Which toe transplant is indicated? LEVEL OF THUMB AMPUTATION AT OR DISTAL TO IP JOINT -Distal IP joint, usually requires no reconstruction. May consider wraparound or trimmed toe reconstruction THROUGH PROXIMAL PHALANX WITH INTACT MCP -APM: great toe transplant – consider wraparound or trimmed be if large great toe and cosmesis paramount DISTAL ½ OF MC TO MCP -Best: great toe -If amputation is proximal to MCP, then oblique osteotomy of 1st MT; foot retained with volar MT head and sesamoids. Dorsal ½ MT head goes with transplant -If amputation is through MCP, may construct a ―composite‖ joint with hand MC head and toe proximal phalanx PROXMAL TO MIDPORTION OF METACARPAL -Need to use 2nd toe -Often need preliminary skin / muscle flap -Often need opposition transfer

PROXIMAL TO THE METACARPAL -Need to use 2nd toe -Base of 2nd toe metatarsal is placed on trapezium and pinned temporarily. This junction forms a pseudojoint over time PARTIAL THUMB LOSS -May cover with partial toe transplant CONSIDERATIONS IN THE FOOT -When great toe is used, amputated at the MTP joint -If use 2nd toe, amputated at the metatarsal base -With the wraparound procedure, the donor site is only marginally better than amputation -2 reasons to use the ipsilateral great toe: (1) vessels are in appropriate place, (2) the great toe has a 10-15 degree angle laterally ANATOMY -Foot has 2 arterial arches: (1) dorsal arterial arch from dorsalis pedis artery, (2) plantar arterial arch from medial and lateral branches of posterior tibial artery -Dorsal arch is usually used and dissected dorsally. Path: anterior tibial artery between EHL and EDL, turns into dorsalis pedis artery at the ankle; crossed by the EHB which should be divided for access. At the base of the 1st intermetatarsal space, dorsalis pedis divides into the

deep plantar artery (=perforation branch) and 1st dorsal metatarsal artery (FDMA). Distally, the FDMA divided into 2 branches that supply the great and 2nd toes -FDMA origin and course is key to the dissection: anatomy is variable. In 2/3 case, FDMA is from dorsalis pedis artery and travels in relatively dorsal plane, either dorsal to the interosseous muscle, within the muscle, or deep to it; but dorsal to the deep transverse metatarsal ligament. In 1/3, the FDMA has another course, either plantar to the deep transverse metatarsal ligament, or arises from plantar arterial arch -2 levels of veins may be used; (1) superficial venous arch which drains into the saphenous venous system (usual), (2) venae comitantes of the dorsalis pedis artery -Medial plantar nerve courses distally into common digital nerves, then proper digital nerves to each side of toe -Deep peroneal nerve divides into 2 dorsal digital nerves that supply adjacent sides of the 1st web space PRE-OPERATIVE PREPARATION -Retain as much length of the thumb amputation as possible. Provide soft tissue cover rather than shorten bone (i.e. groin, scapular, radial forearm flap) GENERAL APPEARANCE AND SKIN FLAPS -Shape and size of toe transplant modeled with clay ARTERIAL SYSTEM -Lateral or oblique foot arteriogram is useful. General anesthetic (in children) or intra-arterial vasodilator (tolazoline 12.5 mg / 70kg) used to eliminate spasm -Upper extremity U/S and physical exam done to outline course of vessels, determine if dominant radial artery or independent radial and ulnar arteries, dominance of digital arteries. If inconclusive, do arteriogram at same time as foot VENOUS SYSTEM -Tourniquet elevated to pressure between systolic and diastolic. Mark dilated SQ veins. OSTEOSYNTHESIS -If need to lengthen, possibly use bone graft, possible partial pollicization with the index metacarpal. -Method of osteosynthesis: (1) interosseous wiring, possibly with step-out osteotomy, (2) hollowed out toe bone and peg thumb to create a mortise and tenon joint-secured with an oblique K-wire -Length is important; should be slightly shorter than other side SURGICAL TECHNIQUE WHOLE GREAT TOE TRANSFER HAND DISSECTION -Incision depends on nature of injury, deformity. Most often, sagittal incision is made to raise radial and ulnar flaps, readily exposing bone -Dissect back to the radial artery at the dorsal 1st web space -The palmer incision is made around the thenar crease and if necessary into the carpal tunnel -The FPL, EPL, and EPB are dissected out; if not available, consider tendon transfers (EIP for extensor, BR for flexor) -Dissect out digital nerves

-Dissect recipient vein in hand, wrist, or forearm -Dissect recipient radial artery at dorsal 1st web space -Make a list of structures and needed transplant length FOOT DISSECITON -Incision to make dorsal and plantar triangular flaps, the dorsal flap covers the FDMA and dorsalis pedis artery and the shorter plantar flap has an apex proximal to the flexion crease. The lateral flap can include skin over the medial 2nd toe if needed -Start with dorsal dissection: SQ dorsal veins, EHL, divide EHB, deep peroneal nerve, dorsal is pedis and FDMA (may have anomalous anatomy, see anatomy section) -If FDMA is absent, dissect the common digital artery from distal to proximal to a point where artery is adequate size for anastomosis (may be easier from plantar approach) -Through a plantar approach, dissect out digital nerves, which are plantar to the vessels. Dissect out the common digital nerve proximally -Dissect the deep peroneal nerve to transplant to the terminal braches of the radial nerve -Dissect the flexor tendon through the plantar incision for 4-5 cm. Use a medial mid-foot and/or medial ankle incision if more length is needed -Divide the bone or capsule at a level complementary to the hand dissection. Release tourniquet to confirm good blood supply TOE-TO-THUMB ATTACHMENT -Fix bone with 90-90 interosseous wiring, K-wires, or combo -Fix tendons: Pulvertaft weave (see ch. 60). EHL to EPL, EHB to EPB, FHL to FPL. If thenar muscles and adductor pollicis present, suture to extensor mechanism. If no thenars, use APB for opposition transfer. When tendon repairs done, thumb should be balanced with IP extended. -Repair dorsalis pedis artery to radial artery (end-to-end, confirm patent ulnar artery first, or endto-side). Repair 1-2 dorsal veins. -Deep peroneal nerve is repaired to radial nerve -Digital nerves sutured in palm -Close skin flaps; skin grafts often needed DONOR SITE CLOSURE -Suture sesamoids to original position (drill holes in metatarsal head may be needed) -Repair deep transverse metatarsal ligament -Drain WRAPAROUND PROCEDURE -Creates narrowed thumb for improved cosmesis -Transfers soft tissue flap and nail from toe, osseous support from iliac crest bone graft, so no movement or growth -Toe dissection: fillet soft tissue off bone (usually retain distal phalanx with fillet); measure needed skin, leave medial skin bridge

TRIMMED TOE TECHNIQUE -Reduces toe size, preserves motion (not as good as whole toe) -Medial toe flap elevated off periosteum -Raise IP medial collateral ligament at its distal insertion with periosteum; raise back to proximal phalanx base. Proximal and distal phalanges longitudinally reduced along radial border 4-6 mm. Replace MCL. Repair skin; narrow nail SECOND-TOE TRANSPLANTATION -Advantages: metatarsal and MTP joint can be included; use if amputation at proximal metacarpal. Better donor site appearance and function. -Disadvantages: (1) transplant narrower than normal thumb, (2) not as strong as great toe -Preliminary flap may be needed -Technique similar to great toe -If metatarsal is included, take a sizable cuff of interosseous muscle; STSG can usually cover -Pin DIP extended x 2-3 weeks -Donor site closure: Repair intermetatarsal ligament; may need to K-wire 1st and 3rd metatarsals PARTIAL TOE TRANSPLANT -Can take parts: 2nd MTP or IP joints 1st web skin, 1st or 2nd pulp, nail / dorsal skin. Often requires toe sacrifice. POST-OPERATIVE CARE -See ch. 33 & 34 -Hand therapy after 1st dressing change in 5 days -Elevate foot x 2 weeks; NWB x 2 weeks SECONDARY SURGERY -Flexor tenolysis, bone grafting, osteotomy, web deepening, tendon transfers, etc. RESULTS -Survival – 95% -Sensibility returns in 9-24 months. 50% patients with < 10 mm 2 point -ROM radial and palmer abduction within 10 degrees of normal. Average IP motion 29 degrees -Pinch/grip strength – with great toe, grip 80-100 %, key pinch 65-169% -Donor site – gait close to normal. No problem running on level ground. 50% with push-off weakness. CHAPTER 42 – THE PERIONYCHIUM (Elvin Zook, Richard Brown)

ANATOMY: -Perionychium=paronychium and nail bed -Nail fold=depression where proximal nail fits into, divided into dorsal roof and ventral floor by the nail

-Nail wall=skin over the dorsum of the nail fold -Eponychium=thin membrane from the nail wall onto the nail dorsum -Lunula=curved white opacity in the nail just distal to the eponychium roughly at junction of intermediate (germinal) and ventral (sterile) matrixes -Nail bed (matrix) is all the soft tissue immediately beneath the nail that participates in nail generation and migration -Hyponychium=mass of keratin between the distal nail and nail bed; very resistant to infection -Nail made from 3 areas of nail bed: ventral floor, dorsal roof, ventral nail bed (sterile matrix) -Blood supply from 2 terminal branches of volar digital artery -Nerve supply from the dorsal branch of the volar digital nerve PHYSIOLOGY: -Complete longitudinal nail growth takes 70-160 days, at a rate of 0.1mm/day or 1.5 inches/year -Fingernails grow 4:1 faster than toenails, and grow faster on longer fingers -Material produced by the roof to the nail fold is responsible for the shiny surface of the nail TREATMENT OF ACUTE INJURIES: EPIDEMIOLOGY – Trauma, infection, self-mutilation, tumor. Door smashing is most common, followed by saws and lawn mowers. 50% with fracture. SUBUNGUAL HEMATOMA (SUH) – Compression laceration of nail bed causes bleeding. Pressure can cause severe throbbing pain. APM: If 50% nail, then remove nail and repair nail bed (although controversial. Seaberg et al in prospective observational study found no major nail deformity or infection with trephination regardless of SUH size-Am J Emerg Med 1991). TREPHINATION TECHNIQUE: Sterile scrub of the finger, cautery (or needle, or heated paper clip). Make sure hole is large enough to assure continued drainage. SIMPLE LACERATIONS – Most common. If nail avulsed (or >50% SUH). REPAIR TECHNIQUE: Digital block, surgical prep, Salem finger tourniquet. Nail removed with Kutz or Freer elevator, scraped clean, and soaked in Betadine. Loupes, 7-0 chromic on micro-point spatula, double-arm GS-9, ophthalmic needle (Ethicon) (APM), may also use 6-0 or 5-0. Nail bed accurately approximated. Round hole drilled or burned through nail at point over repair site to allow drainage. Replace nail under nail fold and hold with 5-0 nylon proximally with horizontal mattress out nail wall. If nail not available, may use 0.020 inch silicone, Adaptic, or Xeroform. Cover with bacitracin ointment, Xeroform, dressing, splint DIP. Change dressing after 7 days and check for SUH or seroma. Start TID soapy water soaks. Suture (holding nail) removed after 2-3 weeks; old nail will adhere for 1-3 months until new nail pushes it off. STELLATE LACERATIONS – RX similar to simple lacerations SEVERE CRUSHING INJURIES – RX similar to simple lacerations; find all nail bed fragments (on nail, etc.-remove with elevator) and replace fragments, repair. LACERATIONS ASSOCIATED WITH FRACTURES OF THE DISTAL PHALANX – If fracture is non-displaced, just use nail as splint. If fracture is displaced, it needs to be accurately reduced and fixed with fine longitudinal or crossed K-wires. If the dorsal cortex of the distal phalanx is uneven, a nail bed deformity will result. If a patient is seen with a nail bed repair, but

displaced fracture, then the wound should be opened, the fracture reduced and pinned, and nail bed re-repaired (unless infection exists-no hardware) AVULSION OF THE NAIL BED – If a large piece of nail plate (with nail bed) is avulsed, then do not remove nail bed from plate, but rather repair nail back to finger accurately. FREE NAIL BED GRAFT – Retrievable fragments of nail bed should be replaced. If adjacent finger amputated or to be amputated, may used full thickness or split thickness nail bed graft; or may get from toe. From toe, remove nail, and take 0.010 inch thick graft with blade. (―no one knows best thickness‖). Graft sutured with fine chromic catgut sutures. DELAYED TREATMENT OF ACUTE INJURIES – Can be addressed up to 7 days post injury. LATE RECONSTRUCTION OF THE NAIL BED – not as successful as the patient or surgeon desire. General principle to excise scar and graft. STSMG if scar involves sterile matrix, FTSMG if germinal matrix involved (from toe) RIDGES – caused by scar beneath nail bed or irregularly healed fracture. Deformity will mimic geometry of scar. SPLIT NAIL – from wide scar that splits nail. NONADHERENCE – diagonal or wide scar makes nail not adhere ABSENCE – may be from congenital, avulsion, severe crush, infection, burn. Resect skin in shape, slightly larger than normal nail and FTSG or STSG; mimcs nail. COMPOSITE NAIL BED GRAFTS – nail bed and nail from usually 2nd toe as donor site. As toe nailbed is shorter than finger‘s, also need STSMG distal to graft. FREE MICROVASCULAR GRAFTS – free graft of tip of toe to tip of finger. PTERYGIUM AND EPONYCHIUM DEFORMITIES CORNIFIED NAIL BED – From keratinized material growing from sterile matrix after germinal matrix is removed to eliminate growth. RX: Excise sterile matrix and apply STSG. NAIL SPIKES AND CYSTS – NAIL CYSTS occur after tip amp and failure to remove all germinal matrix from nail fold. RX: Complete resection of cyst and wall. NAIL SPIKES are from incomplete removal of germinal matrix when removing nail and nail bed for ingrown nail. RX: Complete removal of spike and germinal matrix creating it. HOOKED NAIL – Most commonly from tight closure of fingertip amputation and/or loss of bony support of nail bed. Growing nail follows nail matrix, so do not pull nail bed over distal phalanx to close. If bone is absent, either replace or trim nail bed back to the level of the bone. If hooked nail present, remove nail and trim nail bed back to the level of the bone. PINCER NAIL DEFORMITY- Excess transverse curvature of nail and progressive pinching off of soft tissue of distal fingertip causing pain and deformity. RX: Remove nail plate and elevate nail bed from sides of distal phalanx and placement of dermal grafts under lateral portion of nail bed. INFECTION FUNGAL INFECTIONS – May require nail removal and BID application of 4% Mycolog ointment to the nail bed until nail regrown. Griseofulvin or systemic antifungal may be needed.

BACTERIAL INFECTIONS – Most commonly involve paronychium. Dermal and epidermal layers in paronychium arranged like shingles; when one later is pulled up, an open wound (HANGNAIL) is created. This can be come infected, usually with staph a. Pus may collect on top of or underneath nail, may require partial or entire nail removal, then soapy water soaks TID. Antibiotics if cellulitis present. CHRONIC PARONYCHIA – Usually occurs between nail and dorsal roof of the nail fold. Results in tender, erythematous, swollen fingertip. Usually mixed gram-negative organisms with occasional fungus. RX: moon-shaped excision of nail wall (from skin down to nail) and allow to heal secondarily. BENIGN TUMORS PYOGENIC GRANULOMA – Rapidly growing lesion with round red elevated area similar to granulation tissue growing through nail. Usually result of trauma or iatrogenic. DDX: squamous cell carcinoma, amelanotic melanoma. RX: silver nitrate cauterization. SUBUNGUAL NEVI – Not uncommon. Nail produced by nail bed with pigmented nevus will be pigmented. Nevus may become lighter or darker with time. Possibility for malignant degeneration; need close observation; biopsy nail bed if any question. If atypical cells present, remove involved nail bed. Most common DDX is subungual hematoma, even if no injury known. To determine, scratch the surface of the nail outlining the lesion. If hematoma, it will progress distally with the scratches. If nevus or melanoma, it will not move with scratches (can determine in 3 weeks) VIRAL WARTS (VERRUCA VULGARIS) – Not common in perionychium. RX options: 40% salicylic acid, monochloroacetic acid, 3% formalin. CO2 laser, multiple applications, err superficial. Remove nail if underlying warts. GANGLIONS (MUCOUS CYSTS) – (also see Chapter 67) most common tumor that deforms the nail bed. 10% incidence of persistent minor nail deformity after appropriate RX. Local flaps or grafts not usually needed. If ganglion ruptures through skin, do not operate yet; may lead to infection. Treat with antibiotics until skin is closed, then surgically resect. SUBUNGUAL GLOMUS TUMOR – Rare. Formed from vasculo-musculo-neuro glomus elements of nail bed that affects blood flow. May cause pressure and pain, particularly in cold. May have blue discoloration underneath nail. MRI identifies well. RX: remove nail, incise nail bed and remove tumor. Examine entire nail bed for multiple lesions. Primarily close, may need relaxing incisions in lateral paronychial fold, or may need nail bed graft from toe. GIANT CELL TUMORS (NODULAR SYNOVITIS) – May cause pressure on nail, causing deformity. RX: Complete resection of tumor, may need nail plate removal MALIGNANT TUMORS BASAL CELL CARCINOMA – Rare in hand. RX: If no bone involvement, resect with clean margins, often needs skin graft. If bone involved, or large, or present long time, amputation of distal phalanx or proximal is indicated. SQUAMOUS CELL CARCINOMA – Most common malignant tumor of perionychium, and usually secondary to radiation exposure. Frequently misdiagnosed as paronychia, and average length of time between appearance and treatment – 4 years. Thumb most common digit. RX: If

no bone involvement, resect with clean margins, often needs skin graft. If bone involved, or large, or present long time, amputation of distal phalanx or proximal is indicated. SUBUNGUAL MELANOMA – Usually pigmented with or without nail deformity. Mimicks other conditions: fungal infection, paronychia, warts. RX: amputation at joint just proximal to nail bed that removes tumor, yet preserves function. Prognosis poor (worse for hand and foot melanomas than elsewhere in body). Survival rates: 5-year (30-40%), 10-year (0-13%). CHAPTER 43 – NERVE REPAIR AND GRAFTING (Brushart) ANATOMY EPINEURIUM = loose, collagenous connective tissue which permeates nerve and surrounds individual fascicles; has external and internal component -% of cross-sectional area of nerve composed of epineurium varies (25-75%) PERINEURIUM = tissue layer surround individual fascicles. Functions as blood-brain barrier extension. Removal of perineurium results in loss of function. ENDONEURIUM = collagenous tissue within perineurium; participates in formation of endoneurial tube, which contains axons and Schwann cells VASCULAR SUPPLY: Segmental nutrient vessels join longitudinal epineurial vessels which supply a plexus in the perineurium which supply the endoneurial vascular network FASCICLES = group of axons packed within endoneurium and enclosed by a sheath of perineurium. Smallest unit which can be manipulated surgically. Number of fascicles in a nerve varies greatly (i.e. 3-36 in the median nerve). Fascicles are not separate ―cables‖, but are part of an intraneural plexus FASCICULAR GROUPS: Fascicles are lumped into groups. In clear transections or short gaps, fascicular groups can be matched LONGITUDINAL EXCURSION OF NERVES: -Plexus with arm abducted = 15 mm -Median and ulnar nerves with FROM elbow: 7.3 & 9.8 mm -Median and ulnar nerves with FROM wrist: 15.5 & 14.8 mm -Excursion possible by smooth gliding in its bed and by inherent elasticity DEGENERATION AND REGENERATION WALLERIAN DEGENERATION -Macrophages and Schwann cells clear the distal stump of axoplasm and myelin. Schwann cells form longitudinal columns called Bunger bands -Macrophages produce interleukin-1 (IL-1) which stimulates local production of nerve growth factor (NGF). They also produce insulin-like growth factor I (ILGF-1), an axonal growth promoter -Schwann cells upregulate the growth-promoting molecules L1, laminin, neural cell adhesion molecule (N-CAM), and tenascin SENSORY END ORGANS -Pacinian and Meissner‘s corpuscles may survive years of denervation. There is no definite time in which reinnervation is not useful, but compromise in sensibility will result from delayed repair (Birch, JBJS, 1991) & (Mailander, Microsurgery, 1989). Protective sensibility is goal after denervation of > 1 year.

-Return of sensibility need not be from nerve regeneration; nearby intact axons can undergo collateral sprouting to reinnervate insensate areas DENERVATION CHANGES IN MUSCLE -Ideal reinnervation can be expected after 1-3 months of denervation, functional reinnervation can be expected up to 1 year, and no reinnervation can be expected after 3 years -Some experimental methods to retard muscle atrophy; (1) leupeptin inhibits an enzyme involved with atrophy, (2) electrical stimulator with implanted electrodes may retard atrophy (Nemoto, J Reconstr Microsurg, 1988) & (Nix, Muscle Nerve, 1987), (3) Embryonic motoneuron transplantation (Erb, Exp Neurol, 1993) NEURONAL RESPONSE TO AXOTOMY -Cell death more frequent in young animals (neuron depends on peripheral trophic factors); proximal > distal injury; unrepaired > repaired nerve AXON REGENERATION -Axons form sprouts that search for end organs -Permanent sprouts begin 27 hours after injury -Sprouts that fail to cross repair site may form into a neuroma -Axons that find band of Bunger proceed down -Maximum axon propagation rate = 1-2 mm / day -Regenerating axons demonstrate tissue specificity = preferential growth towards nervous tissue -Neurotropism = directed regeneration toward a substance diffusing from a ―target‖ -Sensory / motor specificity is also demonstrated; probably through neurotrophic (nutritive) support -Topographic specificity = reinnervation of the correct muscle within the motor system or correct patch of skin within the sensory system -End organ specificity = reinnervation of correct type of sensory end organ or correct muscle fiber type *Accurate alignment of axon groups during repair helps specificity of regeneration PRIMARY VS. SECONDARY REPAIR -Primary repair = immediate repair, within hours of the injury -Delayed primary repair = with 5-7 days -Secondary repair = after 1 week *Primary repair is best* -Conditions that must be met for primary repair: (1) sharp nerve transection, (2) minimal wound contamination, (3) well vascularized bed, (4) absence of associated confounding injuries, (5) adequate equipment and staff, (6) patient in adequate mental and physical condition TECHNIQUES OF REPAIR EPINEURIAL SUTURE -Debride ends to healthy nerve -Identify fascicular vascular landmarks and align axon groups

-A single sutures used to join epineurial edges farthest from the surgeon and a 2nd one is placed 180 degrees from the 1st (use 8-0 nylon and leave long tails for manipulation) -Use 10-0 for additional sutures and for smaller nerves GROUP FASCICULAR SUTURE -Isolate each group for about 3-4 mm and then repair groups INDIVIDUAL FASCICULAR SUTURE -Rarely done -May hold with single 10-0 suture, or possibly 2 10-0 placed 180 degrees apart FASCICLE-MATCHING TECHNIQUES -Match axonal groups -May use intraoperative nerve stimulation and /or histochemical staining to aid INTRAOPERATIVE NERVE STIMULATION -Perform only in patient who fully understands and is comfortable -Positively identifies only proximal sensory fascicles and distal motor fascicles -Initial dissection done under 0.5% Bier block; then tourniquet released for 15 minutes. 0.2-0.5 mA nerve stimulation to each fascicle. In the proximal stump, well-localized painful response signifies sensory fascicles; motor fascicles elicit no response at low intensities and poorly localized pain at higher ones -Stimulation of distal stump produces motor contraction in 1st 1-3 days after injury and nothing thereafter HISTOCHEMICAL IDENTIFICATION -Motor and sensory fibers can be identified in proximal stumps indefinitely and distal stumps up to 9 days after axotomy -Acetylcholinesterase (AChE) is in myelinated motor axons -Carbonic anhydrase (CA) is in myelinated sensory axons -Takes a minimum of 1-2 hours POST-OP -Immobilize x 3 weeks; except for digital nerves, mobilize immediately, as long as minimum tension with MCP 60 degrees, IPs 0 degrees SENSORY RE-EDUCATION -Tuning fork, moving touch; blind and viewed -Tactile gnosis, texture and object identification, 2 pd -Desensitize painful dysesthesias RESULTS DIGITAL NERVE -Patient age is most important factor in outcome -75% of patients < 20 years old: 2 pd < 6mm; 25-50% of patients >20 -Better results if repair done within 3 months of injury, poor if > 1 year -Epineurial fascicular suture

MEDIAN AND ULNAR NERVE (adults) -M4 56%, M5 9% -S3+ 36%, S4 10% -Results improve up to 5 years APM PRIMARY SUTURE -Epineurial suture for digital nerves -In elderly patients, repair of all digital nerves not mandatory, i.e. ―nonessential‖ radial little finger, ulnar other fingers. -Group fascicular/epineurial suture other nerves SECONDARY REPAIR -Tension does not permit group fascicular repair, only epineurial repair -Conflicting maximum gap before grafting -Consider grafting if >3 cm gap in major nerve, or if 2 8-0 sutures will not hold -In digit, consider grafting if 10-0 nylon does not hold with MCPs 60 degree and IPs 0 degrees NERVE GRAFTING HISTORICAL REVIEW TYPES OF GRAFT TRUNK GRAFT – Full-thickness graft of major nerve. Not used since central necrosis occurs CABLE GRAFT – Grafts sewn/glued together, then repaired to proximal and distal stumps. Superceded by the more specific interfascicular nerve grafts PEDICLE NERVE GRAFT – see Ch. 39 INTERFASCICULAR NERVE GRAFT (APM) -Better term: Group fascicular grafting. -Fascicular groups identified in the proximal and distal stumps, and joined with 1-2 strands of nerve graft anchored to the internal epineurium with a minimum number of 10-0 sutures. Graft length determined at neutral wrist and elbow extended -4-6 cm gaps preserve fascicular group patterns; with larger gaps, matching becomes more difficult -POST-OP: Passively drain (no suction), immobilize wrist at neutral, elbow at 20 degrees GRAFT LENGTH -For median nerve, < 5cm, 90+% M3/S3, >10 cm, 66% M3/S3 INDIVIDUAL FASCICULAR NERVE GRAFT See ch. 39 -APM: if scarred, avascular nerve bed SOURCE OF GRAFT

AUTOGENOUS NERVE SURAL NERVE GRAFT - APM: For median and /or ulnar nerves, multiple digital nerves ANATOMY -Distally is posterior to lateral malleolus -Distal ½ is superficial, =coursing proximally and medially with the lesser saphenous vein -Receives the sural communicating branch from the peroneal nerve, then dives beneath the gastrocnemius fascia and continue proximally between the 2 gastroc heads to its origin form the sciatic nerve in the popliteal fossa TECHNIQUE – SURAL NERVE HARVEST (see anatomy above) -Position: either supine with bump or prone -If only need 10-20 cm, start distally and harvest distal, SQ portion -If need maximal length; will have to go into popliteal fossa through a chevron incision and transect it off of the sciatic nerve LATERAL ANTEBRACHIAL CUTANEOUS NERVE (LABCN) APM: For 1-2 digital nerves. Use sural nerve if LABCN absent. -The terminal branch of the musculocutaneous nerve, emerges lateral to the biceps insertion and innervates the lateral forearm and occasionally part of the thumb -Harvest through longitudinal incision or multiple transverse incisions MEDIAL ANTEBRACHIAL CUTANEOUS NERVE (MABCN) -May harvest through longitudinal incision beginning 2 cm anterior and 3 cm distal to medial epicondyle -Advantage over LABCN: avoids possible thumb sensation loss; Disadvantage: less length (4 cm) and sensory defect over contact area (APM: does not use) PIN -For distal digital nerve -Harvest through a longitudinal dorsal wrist incision from 5 mm ulnar to Lister‘s tubercle, proximally. It is beneath the 4th dorsal compartment, adherent to the interosseous membrane ALTERNATIVE GRAFTS AUTOLOGOUS VEIN AND MUSCLE -Reversed vein for ―nonessential‖ digital nerves. For vein conduit, 3 cm is maximum length. Results not as good as nerve grafts ALLOGRAFT NERVE -Experimental; need continuous immunosuppression with cyclosporine

ARTIFICIAL CONDUITS -Experimental. Polyglycolic tube, 3 cm is maximum length. Results as good as nerve graft (MacKinnon, Dellon PRS 1988, 1990)

RESULTS OF NERVE GRAFTING -Wide variation of results APM -Interfascicular (group fascicular) nerve grafting -Waits 4-6 weeks for uncomplicated nerve injury, but 3 months if awaiting fracture or flap healing -Re-exploration of graft is rare, but sometimes indicated when Tinel‘s sign has advanced to the graft juncture but not beyond for 2-3 months NEUROMA-IN-CONTINUITY -Diagnosis usually made month after injury -Usually after closed trauma: stretch, fracture, crush, GSW INDICATIONS FOR EXPLORATION: -If Tinel sign remains strong at injury site, but fails to progress x 3-4 months -If Tinel‘s progresses, but function not restored after 2-3 months of expected time -When partial function returns and missing function important TECHNIQUE – EXPLORATION -Intra-operative conduction studies needed: -After dissection, tourniquet released, hemostasis obtained, wound packed in warm, moist sponges for 20 minutes -Test stimulating and recording electrodes 4 cm apart in nerve proximal to lesion, then test across lesion -If no nerve action potential (NAP) across the lesion, then resect neuroma and graft -If NAP crosses, but incompletely, then neurolyse; may need to graft some fascicles FUTURE CONSIDERATION -Molecular manipulations; use of leupeptin, nimodipine, FK 506, probaposin CHAPTER 44 – ENTRAPMENT AND COMPRESSION NEUROPATHIES PATHOPHYSIOLOGY ISCHEMIC / MECHANICAL FACTORS -Probably ischemic etiology secondary to increased pressure, suggested by dramatic reversal of symptoms after surgical decompression. -Reduced epineurial flow at 20-30 mm Hg -Not necessarily inflammatory: Biopsies of tenosynovium of 177 wrists at CTR: 98% with edema and vascular sclerosis, only 10% with inflammatory cells SYSTEMIC CONDITIONS -Some conditions cause depression of peripheral nerve function: DM, ETOHism, hypothyroidism, age TRACTION -Either acute or chronic nerve traction

DOUBLE CRUSH -Compression at one point on a nerve will lower the threshold for compression neuropathy at another point, due to restricted axonal transport GENERAL PRINCIPLES OF DIAGNOSIS AND TREATMENT -Diagnosis has 2 parts: 1) Identify specific nerve lesion, 2) Identify cause SENSORY TESTING -Threshold tests (Semmes-Weinstein monofilaments, vibration) are more sensitive in evaluating compression neuropathies. They evaluate a single nerve fiber innervating a receptor or groups of receptors. -Tests of innervation density (static and moving 2 point) are better in assessing functional nerve regeneration. ELECTRODIAGNOSTIC TESTS -Gold standard, yet has pitfalls: 1) false negative 8-20%, 2) highly operator dependent. NCS: in general, distal motor latencies of > 4.5 ms and distal sensory latencies of > 3.5 ms are considered abnormal. Asymmetry between both hands of > 1 ms for motor and >0.5 ms for sensory conduction is considered abnormal. EMG looks for denervation (fibrillation, positive sharp waves) RADIOGRAPHS -R/o bony deformity, neoplasm, cervical ribs. If h/o smoking, ulnar nerve symptoms, or shoulder pain, get CXR to r/o Pancoast tumor TREATMENT **General treatment principle: Operative if atrophy / weakness. Otherwise, non-operative treatment x 3 months. If worsens, no relief in 3 months, or recurs, then consider surgery CARPAL TUNNEL SYNDROME -Most common compression neuropathy -Only clear risk factors: female, pregnancy, DM, RA -Not universally accepted that job-related factors predict appearance of CTS ANATOMY -Carpal tunnel floor: carpal bones. Ulnar border: hamate hook, Tq, pisiform. Radial border: scaphoid, trapezium. Roof: flexor retinaculum (made of deep forearm fascia, transverse carpal ligament (TCL), and distal aponeurosis). -Superficially: antebrachial fascia, and palmar fascia -Carpal tunnel has the median nerve and 9 tendons (FPL, 4 FDS, 4 FDP) -In the distal forearm, the median nerve runs between FCR and FDS -The palmar cutaneous nerve (PCN) originates from the median nerve 5 cm proximal to the wrist crease, runs with it 1.6-2.5 cm, then run between the PL & FCR before emerging through the fascia 0.8 cm proximal to the wrist crease and dividing into radial and ulnar branches -Variations in the recurrent motor branch of the median nerve: 46-90% extraligamentous, 31% subligamentous, 23% transligamentous. Rarely takes off from ulnar aspect.

-Recurrent motor branch localized at intersection of Kaplan‘s cardinal line (from apex of 1st web space to hamate hook) and long finger flexed to palm -Deep palmar arch lies under Kaplan‘s cardinal line, superficial palmar arch lies slightly distally between Kaplan‘s cardinal line and proximal palmar crease -Variations in median nerve (Lanz): high divisions in the forearm and usually running parallel, possibly with persistent median artery or aberrant muscle running between. DIAGNOSIS HISTORY: pain/hypes/paresthesias palmar/radial 3 ½ digits (hand diagram), thenar weakness, clumsiness PHYSICAL EXAM: Phalen‘s test (75-88% sensitivity, 47% specificity), Tinel‘s (67% sensitivity), positive pressure test = wrist cuff @ 150mm Hg (100% sensitivity, 97% specificity), threshold sensory tests (see above), thenar wasting (late finding) STUDIES: x-ray wrist, electrodiagnostics NOT NEEDED in most cases, but may help if equivocal diagnosis. TREATMENT -Urgent CTR if compartment syndrome, burn, fracture/dislocation -If early CTS (symptoms not constant), then NON-OPERATIVE TREATMENT: splinting in neutral, activity modification, NSAIDs if synovitis, diuretics if edema present, manage medical disorders, consider steroid injection (see below). 3 months of non-operative RX. -If symptoms constant, consider surgery STEROID INJECTION -Steroid injection: 40% symptom free for > 1 year if: 1) symptoms < 1 year, 2) intermittent dullness, 3) normal 2 pd, 4) no weakness, atrophy, denervation on EMG. -Strong correlation between good response from injection and good response from surgery -For all comers, 80% transient relief after steroid injection, but only 22% symptom-free after 12 months -TECHNIQUE OF STEROID INJECTION: 25-gauge needle 1 cm proximal to wrist crease between PL & FCR angled 45 degrees distally. Advance needle until hit floor, then withdraw 5 mm and slowly inject (1 ml dexamethsone mixed with 2 ml 1% plain lidocaine. If paresthesias, then withdraw needle and redirect. OPERATIVE TREATMENT (CTR=carpal tunnel release) -CTR 1st done in 1924 by Herbert Galloway -Options: Open (apm), Limited incision, Endoscopic (1 or 2 portal). Open vs. endoscopic controversial. Endoscopic with nerve injury rate 1.5-2.5X open. Return to work in 1/2 time -MRI shows 24% increase in volume of carpal tunnel after CTR (Richman, JHS, 1989) -No benefit from neurolysis (multiple studies) -If little finger symptoms from ulnar tunnel syndrome (compression at Guyon‘s canal), just release carpal tunnel. Ulnar nerve symptoms should improve. Post-op MRI study showed Guyon‘s canal enlarged after CTR (Silver, JHS, 1985) -Synovectomy only recommended if proliferative tenosynovitis (RA, inflammatory arthritis, , infection-TB). Synovectomy not indicated in routine CTR.

-Reconstruction of TCL indicated if necessary to immobilize wrist in flexion, such as with concomitant flexor tendon repair. TECHNIQUE: Guyon‘s canal unroofed and volar carpal ligament divided. TCL incised making a radial based flap distally and ulnar based flap proximally. The ends of the TCL are then sutured, lengthening the TCL APM: OPEN CARPAL TUNNEL RELEASE -Local or axillary block -Tourniquet 250 mm Hg -Landmarks drawn (see anatomy): PCN, recurrent motor branch, superficial arch, ulnar nerve and artery -Incision made just proximal to Kaplan‘s cardinal line, 2-3 mm ulnar to and parallel with the thenar crease. Extend 2-3 cm into the distal forearm, with ulnar zigzag across the wrist crease (optional) -Gently spread the palmar fascia; preserve cutaneous nerves to avoid persistent incisional tenderness -Sharply divide TCL along ulnar border, identify median nerve. -Bluntly dissect TCL distally, protecting superficial arch and adipose, and deep motor branch of ulnar nerve around hamate hook. -Inspect median nerve and recurrent motor branch; decompress if transligamentous -Retract tendons radially and inspect canal floor for ganglia, osteophytes -Release antebrachial fascia, protecting PCN -Deflate tourniquet, attain hemostasis, irrigate, close skin with 5-0 nylon horizontal mattress sutures CHOW 2-PORTAL ENDOSCOPIC TECHNIQUE (with Seiler‘s modifications) -Anesthesia: local and IV sedation -Entry portal: 1 cm transverse incision 1-1.5 cm radial and 0.5 cm proximal to proximal pole of pisiform. Should be ulnar to palmaris longus. -Make distally based facial flap to visualize the undersurface of the TCL -Exit portal: 1 cm transverse incision 1 cm proximal to the line that bisects the angle formed by the distal border of the fully abducted thumb and 3rd web space. Identify the superficial palmar arch and digital nerves. - Wrist extended 30 degrees and fingers hyperextended, placed in special hand holder -The curved dissector-obturator slotted cannula assembly is inserted under the TCL, along the longitudinal axis of the ring finger -Endoscope inserted proximally and probe inserted distally to identify the distal edge of TCL. Probe knife used to release form distal-to-proximal. Cut the midsection with the triangle knife. Retrograde knife place in the 2nd cut and withdrawn distally. Similar process done proximally AGEE 1-PORTAL ENDOSCOPIC TECHNIQUE -2-3 cm transverse skin incision made between FCR and FCU at the wrist crease -Make distally based fascial flap to visualize the undersurface of the TCL -With wrist in slight extension, rounded probe inserted under the TCL in line with the ring finger. Follow this with the blade assembly, viewing the underside of the TCL with the endoscope. Stop at the distal edge of the TCL, as identified by endoscope, palpation through skin.

-Elevate the blade and withdraw, incising the TCL; may need to make several passes. -Release the volar forearm fascia with scissors. BOWERS‘ LIMITED INCISION TECHNIQUE -Incisions like the Chow technique, but Freer elevator used to dissect under the TCL and protect nerve and tendons while scissors incise TCL in distal-to-proximal direction POST-OP -Immediate independent finger and wrist motion. In prospective randomized study of 50 patients s/p CTR +/- immobilization, no bowstringing or wound problems in either group, and immobilization found to be detrimental to return to ADL, work, strength (Cook, JHS, 1995). RESULTS OF CTR -96% patient satisfaction and symptom improvement. 84% return to original jobs. (Osterman, Orthop Clin, 1988)

MEDIAN NERVE COMPRESSION IN THE DISTAL ARM AND PROXIMAL FOREARM -Fibers of the AIN are posterior and sensory fibers are anterior in the median nerve at the elbow. Because of this topographic arrangement, it is possible to compress either the motor or sensory fibers. -Gantzer‘s muscle = accessory head of FPL can compress median nerve. Present in 45%. -AIN also supplies sensory fibers to RC, intercarpal, CMC, and DRUJ. PRONATOR SYNDROME -Rare: Less than 1% of compression syndromes PATHOANATOMY: possible sites of compression: (―LLPA‖ ) 1. Ligament of Struthers or supracondylar process = inconstant fibrous arch from supracondylar process to medial epicondyle 2. Lacertus Fibrosus = bicipital aponeurosis, inserts on proximal ulna 3. Pronator Teres 4. Arch of FDS DIAGNOSIS HISTORY: Pain at proximal volar forearm, increased with activity. Hypes/paresthesia palmar radial 3 1/2 digits AND PALM! Muscle cramps (―writer‘s cramp‖) PHYSICAL EXAM: Tender and positive Tinel‘s @ FOREARM, NEGATIVE PHALEN‘S. Threshold testing (see above). Provocative tests: (1) Resisted elbow flexion with forearm supinated tightens Lacertus Fibrosus, (2) Resisted forearm pronation with elbow fully extended tightens Pronator Teres, (3) Isolated middle finger PIP flexion tightens Arch of FDS. STUDIES: Elbow x-rays, including obliques to r/o supracondylar process. Electrodiagnostics confirm fewer than 50%. Nerve conduction velocities in proximal forearm are reduced in 2032% CTS (retrograde nerve degeneration).

TREATMENT NON-OPERATIVE: Modification of provocative activities. Immobilize in long arm removable splint with elbow 90 degrees, forearm slight pronation, wrist slight flexion. NSAIDs. 50% success. OPERATIVE: If fail non-operative treatment, explore and release median nerve at all sites. TECHNIQUE: Incision 5 cm proximal to elbow flexion crease medial to the biceps tendon, curves laterally across the antecubital crease and then down the forearm 5 cm. Identify and protect the medial antebrachial cutaneous nerve next to the basilic vein. Identify and tag the median nerve proximal to the elbow. Transect the Ligament of Struthers and excise the supracondylar process. Transect the Lacertus Fibrosus. Tendinous or fibrous bands in the Pronator Teres (PT) are incised. If visualization and release are inadequate, the insertion of the PT superficial (humeral) head is released and tagged for later reattachment. If a variant exists where both nerves are deep to both heads (the PT deep (ulnar) head also), then the deep head may need to be released and tagged as well. Incise the Arch of the FDS. Reattach the PT if needed. Another possible variant: a median artery that penetrates then median nerve should not be ligated, but passage for the artery should be enlarged by interfascicular dissection, since it can be its dominant blood supply in 30%. Constricting median artery branches can be ligated. Postop immobilization (see non-operative splint) for 1 week, then gentle ROM.

ANTERIOR INTEROSSEOUS SYNDROME PATHOANATOMY: Similar to pronator syndrome, except compression usually at PT or FDS DIAGNOSIS HISTORY: Weakness of pinch (FPL, radial 2 FDP, PQ). Pain @ proximal volar forearm, increased with activity. NO SENSORY DEFICIT. Can occur after forearm fracture (bone spike) PHYSICAL EXAM: Cannot perform ―O.K.‖ sign, but assumes classic position of: loss of flexion of index DIP and thumb IP, with compensatory hyperflexion of index PIP and thumb MCP. Weak pronator quadratus identified by resisting pronation with elbow maximally flexed, which eliminates the humeral head of the PT, which lends 75% strength of pronation. STUDIES: Electrodiagnostics after 3 weeks since onset. Differential Diagnosis: Parsonage-Turner syndrome (=paralytic brachial neuritis), a syndrome of unknown etiology of pain in shoulder, arm, elbow, forearm and atrophic paralysis; possibly bilateral; electrodiagnostics may be similar to AIN syndrome. Treatment is observation; spontaneous recovery in 1-3 years, but may recur. TREATMENT Similar to Pronator Syndrome, but if no clinical or electrodiagnostic improvement after 2-3 months of non-operative treatment, then surgery (see above) is indicated.


DIAGNOSIS HISTORY: pain/hypes/paresthesia ulnar 1 1/2 hand (volar AND DORSAL), pain at medial elbow, weak grip. Due to nerve topography at elbow (sensory fibers more superficial), sensory changes occur before motor changes. PHYSICAL EXAM: Sensory changes ulnar 1 ½ volar and dorsal hand. Tender ulnar nerve at elbow, positive Tinel‘s at elbow (24% false positive-Rayan, JHS, 1992), positive elbow flexion test (60 seconds, supinated; also 24% false positive-Rayan, JHS, 1992), weak grip, weak / atrophied muscles. Also due to topography, intrinsics are affected first, then FDP to 5th, FDP to 4th variable, FCU last and rarely. ROM elbow, look for subluxing ulnar nerve. -Intrinsic tests: Froment‘s sign, Mumenthaler‘s sign (failure wrinkle palmar skin due to palmaris brevis weakness), Egawa‘s sign (failure to ab/adduct the middle finger) -Martin-Gruber Communication (6-44% incidence in literature): In forearm, communication from median nerve to ulnar nerve. Some motor only, some mixed. Bilateral in 20%. -Examine to rule out cervical disc disease, TOS (see ch. 45). STUDIES: Radiographs of elbow to look for osteophytes, lesions. Electrodiagnostics help to confirm. CXR if h/o smoking, ulnar nerve symptoms, and shoulder pain; look for Pancoast tumor compressing/invading inferior brachial plexus. PATHOANATOMY -Usually caused by constricting structures (see below). May also be from soft tissue pathology (hypertrophic synovium, tumor, ganglia, epitrochleoanconeus muscle), bony pathology (cubitus valgus, osteophytes), ulnar nerve subluxation. -5 possible sites of compression: (1) Medial intermuscular septum, Arcade of Struthers (present in 70%) is 8 cm proximal to the medial epicondyle and is formed by the intermuscular septum, medial head triceps fascia and fibers, and internal brachial ligament (which runs from the coracobrachialis insertion to the intermuscular septum). (2) Medial epicondyle, (3) Epicondyle groove, (4) Cubital Tunnel, bounded by Osborne‘s Fascia (=arcuate ligament=triangular ligament) (5) FCU aponeurosis TREATMENT NON-OPERATIVE -Avoid elbow hyperflexion, resting weight on elbow -Elbow pad during day. At night, towel wrapped around elbow, reversed elbow pad. Temporary splinting (3-4 weeks) may be needed: elbow at 40 degrees, wrist neutral. -Do not perform steroid injection OPERATIVE -Decompress nerve at all 5 sites, then anterior transposition (options: subcutaneous, submuscular, intramuscular). Other options: in situ decompression, epicondylectomy. -Most surgeons perform either submuscular or subcutaneous transposition (advantages of transposition: better bed and relieves nerve tension). -Dellon, JHS, 1989: Review of 50 articles. 50% cured non-operatively, nearly 100% operatively. For mild compression, no difference. For moderate to severe compression, submuscular transposition best. Submuscular best for re-operations.

-Subcutaneous transposition: Advantages: best in fracture/dislocation surgery, arthroplasty. Controversial if better in throwing athlete (does not detach muscle as in submuscular). Disadvantages: Uncovered in thin patient (obese patient with thick skin may not be as much an issue) -Submuscular transposition: Advantages: Muscular protection and vascularized bed. Disadvantages: need muscular healing after reattachment. SUBMUSCULAR TRANSPOSITION - OPERATIVE TECHNIQUE Incision 8-10 cm proximal to medial epicondyle over medial intermuscular septum (MIS) and 57 cm distally, centered between olecranon and medial epicondyle. Alternatively, midline posterior incision down to triceps fascia (if raise thick flap, cutaneous nerve should be safe in flap; obviates need to identify). Raise thick skin flaps exposing MIS and flexor-pronator fascia. Protect posterior branches of medial antebrachial cutaneous nerve, the location of which is variable, from 6cm proximal to 4 cm distal to the epicondyle; 90% are at or proximal (Masear, JHS, 1989). Release 5 compression sites, excising MIS. Sacrifice first branch off ulnar nerve: sensory branch to elbow joint (Hilton‘s law: when a nerve crosses a joint, it gives sensory branches to it), but protect motor branches to FCU. Do not perform internal neurolysis (compromises blood supply). Identify the anterior aspect of the flexor-pronator (interval with brachialis) and start raising the flexor-pronator origin from that point. Distally, sharply raise flexor-pronator from the ulnar collateral ligament by raising ―red‖ = muscle off of ―white‖ = UCL. Continue raising flexor-pronator off of the medial epicondyle sharply with 15 blade, approximately 5 cm. Transpose the ulnar nerve submuscularly, and reattach the flexor-pronator through 4 drill holes (0.062 inch drill or K-wire) in the medial epicondyle, using mattress sutures and 0-ethibond. Repair remaining flexor-pronator aponeurosis. At end of procedure, check full elbow ROM to assure no kinking of nerve. Mobility should be verified from 10-12 cm proximal to 5-10 cm distal to the epicondyle. Immobilize in splint, elbow at 45 degrees, wrist neutral. SUBCUTANEOUS TRANSPOSITION - OPERATIVE TECHNIQUE As above, but mark skin 1.5 cm anterior to medial epicondyle before incision. Make a 2 x 1.5 cm fascial sling (from flexor-pronator fascia) and attach to SQ tissue to hold nerve anteriorly. ULNAR TUNNEL SYNDROME = compression at Guyon‘s canal -Guyon, a French urologist, described the canal in 1861 ANATOMY -Guyon‘s canal = Roof: VCL. Floor: TCL. Ulnar border: pisiform. Radial border: hamate hook -3 Zones of ulnar nerve: (1) Zone 1: proximal to bifurcation. Compression here causes combined motor and sensory disturbance. (2) Zone 2: radial deep motor branch. Compression here causes only motor disturbance. (3) Zone 3: ulnar superficial sensory branch. Compression here causes only sensory disturbance. PATHOANATOMY -Usually definite cause (unlike CTS): Ganglia from TqH joint – 85% of nontraumatic causes. Ganglia and other soft tissue masses account for 32-48% of all causes. 16% due to muscle anomalies. Other causes: hamate hook fracture, thrombosis or pseudoaneurysm of ulnar artery, inflammatory arthritis, edema (from trauma, burn).

DIAGNOSIS HISTORY: Pure motor, sensory, or combined depending on exact location of compression. Wrist pain, pain/hypes/paresthesia VOLAR ulnar 1 1/2 digits. Intrinsic weakness, eventual clawing of ulnar 2 digits. Sustained wrist hyperextension or hyperflexion exacerbates symptoms. PHYSICAL EXAM: Tenderness, swelling, mass, bruit over Guyon‘s canal. Positive Tinel‘s at canal, positive Phalen‘s test. -Test intrinsic strength; positive Froment‘s sign / intrinsic wasting -Test sensibility with threshold tests -Allen test to evaluate patency of ulnar artery STUDIES: X-ray wrist (with carpal tunnel view and oblique views) and/or CT may reveal hamate hook fracture. MRI may reveal ganglia, soft tissue mass, pathologic artery, etc. Doppler may reveal pathologic artery. Electrodiagnostics may establish diagnosis TREATMENT NON-OPERATIVE: If no identifiable lesion, avoid repetitive activity, removable neutral wrist splint, NSAIDs OPERATIVE: If identifiable lesion or fails 3 months of non-operative treatment. Special case: If acute ulnar neuropathy after wrist fracture progresses or does not improve after 24 hours, then emergent decompression indicated. OPERATIVE TECHNIQUE Ulnar nerve should be explored proximally from distal forearm, distally into palm throughout all 3 zones. Skin mark FCU, pisiform, and hamate. Incision begins 3 cm proximal to the wrist crease, radial to the FCU, crosses the wrist crease at 60 degree zig, apex radial, continues distally between the pisiform and hamate, then angles across the palm proximal and parallel to the proximal palmar crease. Identify and tag the ulnar nerve with a small Penrose drain. Divide the forearm and palmar fascia. Elevate the palmaris brevis muscle ulnarly and divide the VCL and the pisohamate (PH) ligament. Incise the thick arch of the hypothenar muscles just distal to the PH ligament. Trace out the deep motor branch. Explore the floor for masses, bands, fractures, anomalous muscles and excise as needed. Inspect the ulnar artery. Post-op, splint in 20 degrees extension for 2 weeks. RADIAL NERVE PROXIMAL RADIAL NERVE COMPRESSION -Radial nerve compression proximal to the elbow is rare -Associated with strenuous muscular activity -Associated with fibrous arch from lateral head of triceps, humeral exostosis DIAGNOSIS HISTORY: Weakness in radial nerve and PIN innervated muscles. Sensory deficiencies. PHYSICAL EXAM: As above STUDIES: Electrodiagnostics are helpful TREATMENT

NON-OPERATIVE: Recovery usually occurs in 1 month. OPERATIVE: If no sign of recovery in 3 months, surgical decompression is indicated. SURGICAL TECHNIQUE Lateral decubitus position. Start incision below posterior axillary crease between deltoid and lateral head of triceps, extend distally between biceps and lateral head of triceps, cross lateral intermuscular septum obliquely 10 cm about lateral humeral epicondyle, and extend between biceps and BR, end at antecubital crease. Find lateral antebrachial cutaneous nerve in the distal wound between the biceps and brachialis and tag (do not confuse with radial nerve). Find and tag the radial nerve distally between BR and brachialis muscles, and trace it proximally to where it pierces the lateral intermuscular septum; incise the septum and expose the radial nerve under the lateral head of triceps. Long and lateral heads of triceps divided, as well as teres major and latissimus dorsi. All these tendons should be reattached after exploration is completed. DISTAL RADIAL NERVE SYNDROMES **Both radial tunnel syndrome and PIN syndrome arise from PIN compression in the radial tunnel (=from radiohumeral joint to Arcade of Frohse), but radial tunnel syndrome is PAIN/NO WEAKNESS, while PIN syndrome is WEAKNESS/NO PAIN!!!(except at dorsal wrist-capsule) RADIAL TUNNEL SYNDROME ANATOMY: Radial nerve gives 1-3 branches to brachialis 3-9 cm above epicondyles, 1-3 branches to BR 3-6 cm above epicondyles (BR can arise from superficial radial nerve distal to epicondyle), 1-3 branches to ECRL 6cm above to 2.5cm distal to epicondyle. Radial nerve emerges anterior to lateral epicondyle and bifurcates into superficial and deep (=PIN) branch. Superficial branch courses under BR until it pierces fascia between BR & ECRL 7-9 cm proximal to wrist. ECRB may be innervated by PIN, radial nerve, or least commonly superficial branch. PATHOANATOMY: Possible sites of compression (mnemonic ―FREAS‖): (1) Fibrous bands (anterior to radial head), (2) Recurrent radial vessels (=leash of Henry), cross PIN to supply mobile WAD, (3) ECRB (fibrous edge), (4) Arcade of Frohse (fibrous proximal edge of supinator-most common site), (5) Supinator (distal border) DIAGNOSIS HISTORY: Often associated with repetitive forearm rotation, elbow extension. Deep, aching pain 5 cm distal to lateral epicondyle, increased with activity. NO MOTOR/SENSORY LOSS PHYSICAL EXAM: Tender 5 cm distal to lateral epicondyle. Provocative tests: (1) Passive pronation with wrist flexed, (2) Resisted Supination with extended elbow, (3) ―Middle finger test‖: with elbow extended and neutral wrist, resisted middle finger extension. STUDIES: Electrodiagnostics not helpful. **positive block test (lidocaine @ site: relief of pain with PIN palsy) TREATMENT NON-OPERATIVE: Should always be tried first: rest, activity modification, NSAIDs, splint (elbow flexed, forearm supinated, wrist extended) OPERATIVE: Decompress nerves at all sites (above)

SURGICAL TECHNIQUE (APM): Approach between BR-ECRL proximally and Thompson distally. Make a gentle curved S-shaped incision 8-10 cm long starting at lateral epicondyle and aiming along the axis between the lateral epicondyle and the long finger. Identify and protect the lateral antebrachial cutaneous nerve. Locate the radial nerve proximally between the BR and brachialis. Incise the fascia and develop the interval between the BR and ECRL from the radiocapitellar joint to the middle of the supinator. Identify and tag the superficial and deep branches of the radial nerve. Develop the interval between the ECRB and EDC to expose the supinator. Divide fibrous bands over the PIN and fibrous edge of the ECRB. Ligate the recurrent radial vessels (leash of Henry). Section the arcade of Frohse longitudinally. Release the superficial head of the supinator, including its distal edge. POST-OP: Long arm splint with elbow 90 degrees and forearm and wrist neutral. POSTERIOR INTEROSSEOUS NERVE (PIN) SYNDROME PATHOANATOMY -Compression sites same as radial tunnel syndrome. -Can also be from trauma (radial head fracture or dislocation), mass (rheumatoid synovitis, lipoma, ganglion), iatrogenic DIAGNOSIS HISTORY: PIN palsy (incomplete more commonly). Dorsal wrist pain PHYSICAL EXAM: +Radial wrist extension,-Neutral or ulnar wrist extension. -MP extension, +IP extension. No sensory loss. Differentiate from tendon rupture by tenodesis check STUDIES: X-rays of elbow. Electrodiagnostics helpful. MRI to evaluate for mass TREATMENT NON-OPERATIVE: If no known lesion, trauma, long standing weakness. Rest, activity modification (avoid repetitive rotation, wrist flexion), splint (frequently resolves spontaneously) OPERATIVE: Indicated if known lesion, iatrogenic (plate proximal radius), progressive, refractory to 2-3 months of non-operative treatment. Good to excellent results in 85%. Surgical approach as in radial tunnel syndrome SUPERFICIAL RADIAL NERVE COMPRESSION SYNDROME (=Wartenberg‘s Syndrome=Cheiralgia Paresthetica) DIAGNOSIS HISTORY: pain/hypes/paresthesia dorsal radial hand and 3 1/2 digits, exacerbated by wrist movement or pinch EXAM: Positive Tinel‘s, tender nerve. Provocative test: maximum pronation for 60 seconds. Positive Finkelstein test (must differentiate from de Quervain‘s, although they may co-exist) STUDIES: Differential injections. Electrodiagnostics may help. PATHOANATOMY: Superficial radial nerve runs under BR, and exits between BR and ECRL 9 cm proximal to wrist, proceeds to multiple branches.

-Causes of syndrome: (1) Repetitive activity (screwdriver, writing, typing) may compress nerve between BR and ECRL, (2) Site of external compression (jewelry, handcuffs) or abnormal fibrous bands, (3) Traumatic injury to nerve (direct blow) TREATMENT NON-OPERATIVE: Remove offending object, activity modification, splint, NSAIDs, cortisone injection OPERATIVE TECHNIQUE: 6 cm incision starting 2 cm proximal to radial styloid and aiming towards lateral epicondyle. Identify the nerve and release the fascia between the BR and ECRL proximally and distally. If the nerve pierces the BR (3-10%), then excise the constricting portion of BR. CHAPTER 45 – THORACIC OUTLET SYNDROME (Jones, Henry) -Difficult to diagnose and treat -Reasonable number of patients will not become pain free or ever return to ―preinjury‖ level of function despite surgical or nonsurgical treatment WILBOURN‘S CLASSIFICATION -2 basic types of TOS and 4 subtypes. 2 basic types are vascular and neurogenic. Vascular subdivided into arterial and venous subtypes. Neurogenic subdivided into ―true‖ and ―disputed‖ subtypes -VASCULAR, ARTERIAL SUBTYPE: Uncommon, 1-2% of all TOS. May present with 4 P‘s of ischemia (pain, pallor, pulselessness, paresthesias), cool extremity in acute thrombosis or embolism. In less severe cases, unilateral Raynaud‘s, fingertip ulceration, claudication. Fully developed cervical rib seen in 50%. VASCULAR, VENOUS SUBTYPE: 2-3 % of all TOS. Presents with pain, edema, & cyanosis in cases of sudden, effort-induced thrombosis (Paget-Schroetter syndrome), or infrequently thrombosis at rest with extremity in prolonged compromised position. This is in contrast to cases of intermittent compression where collaterals exist which drain the extremity but cause fullness of the shoulder and chest -NEUROGENIC, ―TRUE‖ SUBTYPE: Rare, 1:1 million patients. Always caused by bony anomaly. Present with pain and paresthesias, hypothenar atrophy. Findings on physical exam: decreased grip strength, sensory deficits, usually C8-T1. NEUROGENIC, ―DISPUTED‖ SUBTYPE: Most common, 97% of all TOS. Accounts for most controversy regarding TOS. No set diagnostic criteria, no ―gold standard‖ treatment. Patients present with wide variety of vague complaints; usually no objective findings on x-rays, electrodiagnostics, Doppler, pulse volume recordings. Physical complaints reproduced by provocative testing; in absence of another diagnosis, H&P is sufficient to make the diagnosis of TOS. EPIDEMIOLOGY -5 predisposing factors: (1) sex (female 3.5 : male 1.0), (2) age (37), (3) occupation (ones with repetitive arm movements with the hand at or above shoulder, awkward posture, lack of rest; i.e.

store cashier, hairdresser, painter, construction worker, nurse, secretary), (4) geographic location (more common in CA, CO; rare in countries where cumulative trauma disorder not recognized), (5) insurance status (more commonly diagnosed if privately insured or worker‘s comp) ANATOMY -Thoracic outlet partitioned into 3 sections: (1) interscalene triangle, (2) costoclavicular triangle, (3) subcoracoid or pectoralis minor space INTERSCALENE TRIANGLE -Defined anteriorly by anterior scalene, posteriorly by middle scalene, inferiorly by 1st rib -Subclavian vein passes anterior to anterior scalene and inferior and lateral to the costocoracoid or costoclavicular ligament -Nerve roots and subclavian artery pass through the triangle -Anterior scalene originates from anterior tubercles of the transverse processes of C3-6. Middle scalene originates from posterior tubercles of transverse processes of C2-7. Both insert into 1st rib as base of ―triangle‖, but anomalies possible of ―V‖ or ―U‖ at base -Cervical ribs in 0.5% of population, 50-80% bilateral. Many are incomplete, but have tight fibrous bands -Many other bands exist, most commonly, bowstring across 1st rib concavity, scalenus minimus muscle band, bands between nerve roots from anterior to middle scalene COSTOCLAVICULAR SPACE -Bounded anteriorly superiorly by clavicle, subclavius muscle, and costocoracoid ligament; posteromedially by the 1st rib; posterolaterally by the superior border of the scapula -Hypertrophied subclavius tendon can compress the subclavian vein as in Paget-Schroetter syndrome SUBCORACOID OR PECTORALIS MINOR SPACE -Compression by 3 mechanisms (1) within arm abduction, neurovascular bundle stretches around the coracoid, (2) external scapular rotation accentuates #1, (3) abduction tenses the pectoralis minor tendon CLINICAL FINDINGS -Paresthesias in 95% TOS; most common initial complaint. Usually ulnar nerve distribution, but can be whole arm. -Insidious, chronic pain in the shoulder, neck, upper back, upper extremity. Pain is dull, nagging, throbbing -Easy fatigability Symptoms increase with driving, grooming -Nighttime complaints are common; some need narcotic, tricyclics, benzodiazepines to sleep -Double crush phenomenon=mild proximal nerve compression does not cause clinical symptoms on its own, but makes the nerve more susceptible to distal compression. -May c/o swelling, coolness, discoloration -May have numerous other complaints: headache, vertigo, memory loss, syncope, etc. -Also may have depression, anger. Multispecialty treatment (psychiatric/ psychologic) is very important PHYSICAL EXAMINATION -97% diagnosis made by physical exam

-Must remove all concealing clothing, jewelry, hair -Pain questionnaire is essential -Look for clues of muscle imbalance. Note general appearance: Slouching? Large breasted? Grooves in shoulders from bra? Neck held to 1 side? 1 shoulder drooping? -Look for masses, fullness, collaterals. -Note tone of muscle. Palpate, test strength. -Record circumferential difference between sides -Test sensation by moving and static 2-point and Semmes-Weinstein monofilaments -Evaluate reflexes -Listen to subclavian region for bruits -Check for tenderness, especially of scalene, clavicle, brachial plexus -Test for distal compression (see Ch. 44), tendonitis, rotator cuff, cervical radiculopathy before provocative TOS tests PROVOCATIVE TESTS FOR TOS -For test to be positive, patient‘s symptoms must be reproduced and/or radial pulse diminished or obliterated ADSON‘S TEST (=SCALENE TEST) -Arm at side, patient hyperextends neck, turns face toward affected side, inhales deeply WRIGHT‘S HYPERABDUCTION MANEUVER -Arm abducted 180 degrees and externally rotated, patient inhales deeply. Elbow only slightly flexed (to minimize cubital tunnel pressure), Hold for 1 minute ROOS‘ TEST (=90 degrees abduction external rotation test = stick-up test) -Patient hold both arms up with arms 90 abducted, 90 ER, elbows flexed 90 degrees. Pumps hand open and closed quickly and repetitively x 3 minutes. Positive test: symptom reproduction and/or rapid fatigue HALSTEAD MANEUVER (=COSTOCLAVICULAR TEST=MILITARY BRACE TEST) -Both arms at side, patient moves shoulders downward and backward with chest protruding to draw the clavicle closer to the 1st rib, narrowing the thoracic outlet CERVICAL ROTATION LATERAL FLEXION TEST -Evaluated for subluxation of the 1st rib, this has been shown to limit cervical rotation combined with lateral flexion -Begin test in neutral position. Neck is maximally rotated away from affected side, then flexed forward maximally so ear moves toward chest. Test is positive if bony block to lateral flexion and asymmetry to contralateral side; may also reproduce symptoms PENCIL DOPPLER PROBE -Listen to subclavian, axillary, brachial artery and vein for bruits, pitch difference, diminution/obliteration of signal with provocative maneuvers. STUDY REGARDING PROVOCATIVE TESTS -(Warren & Heaton, Ann R Coll Surg Engl, 1987): Single positive test probably meaningless, more than 2 positive tests significant. 64 random volunteer subjects, 58% had 1 of 4 positive

tests (Adson, Wright, Halstead, supine hyperabduction), but only 17% with TOS symptoms. Only 2% had more than 2 positive tests. DIAGNOSTIC STUDIES RADIOGRAPHIC EVALUATION -Plain x-rays of cervical spine and chest are part of initial evaluation; other extremity films may be warranted based on H&P -Color duplex sonography (ultrasound) can visualize stenoses, thrombosis, flow problems in arteries and veins. 92% sensitive, 95% specific for TOS. -Pulse volume recordings or photoplethysmography may suggest arterial compression -If clinical urgency of ischemia, embolism, thrombosis, then go directly to ―gold standard‖ of angiography or venography. -Invasive vascular studies only indicated if physical evidence of vascular compression -Venography with extremity in provocative positions may be needed in intermittent / exercise induced cases with normal baseline venogram. May visualize abundant collaterals. -Especially in arterial and ―true‖ neurogenic cases, if plain x-rays negative, then perform CT scan. (Bilbey, Radiology, 1989: CT identified bony anomalies in 8 of 12 patients with ―normal‖ plain x-rays). CT of low yield and not recommended in routine patients with ―disputed: neurogenic TOS (Novak, JHS, 1993) -MRI has not been found to be beneficial; except c-spine MRI if radiculopathy suspected -MRA may have a future role ELECTRODIAGNOSTIC EVALUATION -EMG/NCS are part of routine work-up -May reveal a distal nerve compression syndrome and treatment may relieve some if not all symptoms -Somatosensory evoked potentials (SSEP‘s) controversial -Typical patient with ―disputed‖ neurogenic TOS will have normal studies -―True‖ neurogenic TOS may show EMG abnormalities early, followed by NCS changes late TREATMENT NON-OPERATIVE TREATMENT -Non-operative treatment is 1st line of treatment for all ―disputed‖ neurogenic TOS -Risk factors for failure of non-operative treatment include obesity, poor cardiovascular conditioning, lack of multi-modality treatment 4-STAGED PROGRAM STAGE I (goal: relieve pain and control progression) -Identify and treat myofascial trigger points, local spasm, tendonitis/bursitis -Consider NSAIDS, muscle relaxants, mild narcotics, anti-depressants, sleeping aids or centrally acting drugs: amitriptyline (Elavil), carbamazepine (Tegretol), or gabapentin (Neurontin) -Moist heat and/or ice, transcutaneous electrical nerve stimulation (TENS), ultrasound STAGE II

-Stretch, relaxation, breathing to restore normal mobility and balanced posture to cervical and thoracic spine, shoulder girdle -Correct common pathologic slouched posture of increased cervical lordosis, thoracic flexion, shoulder internal rotation. This leads to short, tight anterior muscle groups and elongated posterior groups -Also look for lumbar lordosis, leg length discrepancy -Consider brachial plexus gliding and peripheral nerve mobilization STAGE III -Muscle strengthening, increasing endurance. Set realistic goals; if too vigorous, may exacerbate symptoms STAGE IV -Home program: scalene stretching, cervical pro & retraction, diaphragmatic exercises, pectoralis stretching, shoulder circumduction. 10x‘s each, 3x‘s/day -Return to work, Analyze job site. Life and work ―hygiene‖: take breaks for stretching, breathing, relaxation RESULTS -Variable and hard to compare since lack objective findings in ―disputed‖ neurogenics -Approximately 50-100 % success OPERATIVE TREATMENT INDICATION: (1) failure to respond to conservative program, (2) intractable pain, (3) ―true‖ neurogenic group, (4) vascular groups -Early or urgent surgery for arterial decompression -Indications for ―disputed‖ neurogenic group controversial SURGERY -Includes (1) excision or release of any anomalous anatomy, (2) resection of 1st rib, (3) release or excision of anterior and middle scalene muscles, (4) possible neurolysis of brachial plexus SURGICAL APPROACH -Either transaxillary, supraclavicular or both; surgical results similar. Matter of personal preference WHO PERFORMS SURGERY -TOS surgery usually performed by vascular or thoracic surgeon; with possible collaboration with hand surgeon to explore, neurolyse, mobilize the brachial plexus -Vascular/thoracic surgeon may need to perform arterial reconstruction, thrombolysis, etc. -Generally no need for long-term anticoagulation, unless hematologic predisposition for thrombosis COMPLICATIONS NON-OPERATIVE TREATMENT -Complications few -Exacerbation of symptoms if therapy too vigorous -Drug dependency, psychiatric disorders

OPERATIVE TREATMENT -Can be devastating: great vessel injury, nerve injuries, etc. -Cutaneous nerve injury almost universal; usually resolves -High rate of litigation associated with TOS surgery RESULTS NON-OPERATIVE 4-STAGE PROGRAM: -70% partially or almost completely better, 10% no better, 10% completely better (Novak, JHS, 1995) OPERATIVE 80% good-excellent results RECURRENT SYMPTOMS AFTER SURGICAL TREATMENT -―Failed‖ surgery 5-25% -May be from missed diagnosis: OA, cervical disease, Pancoast tumor, etc. -May be from inadequate decompression -May need re-operation. Remove scar, offending structures. Supraclavicular approach most popular, since better access to plexus, use fat to wrap plexus to decrease adhesions. -Results re-operation: 74-90% improved early (3 months), 60% failed at 10-15 years CHAPTER 46 – NEUROMAS (Herndon) CLASSIFICATION OF NEUROMAS NEUROMAS-IN-CONTINUITY (NIC) = Neuromas in a nerve that has not been completely severed. SPINDLE NEUROMAS = NIC with intact perineurium. Swellings in intact nerve due to chronic irritation, friction, or pressure. Not true neuromas. Examples: Morton‘s metatarsalgia, meralgia paresthetica. LATERAL NEUROMAS = NIC where perineurium of some funiculi are broken. Often from trauma. Treatment in Ch 43. NEUROMAS FOLLOWING NERVE REPAIR NEUROMAS IN COMPLETELY SEVERED NERVES – Classic neuroma that surgeons encounter AMPUTATION STUMP NEUROMAS – Like above, but subject to repeated trauma and fibrosis. DIAGNOSIS – Positive Tinel, palpable mass. If difficult to assess, may consider differential diagnostic blocks first with saline, then lidocaine. TREATMENT

RESECTION – TECHNIQUE: Find the nerve in a normal area, isolate the neuroma, dissect the nerve free proximally. The proximal limit is an area of healthy tissue, free of scar, where the new nerve end will be well covered and protected. Gentle traction on nerve and section nerve as far proximally as possible. LIGATION – Controversial. Dissect nerve proximally and tie non-absorbable suture 5-10 cm above severed end. TRANSPOSITION WITH IMPLANTATION - Transposition with implantation into same nerve (neurocampsis), muscle, bone, another nerve. RELOCATION OF INTACT NEUROMA – TECHNIQUE: Isolate intact neuroma. Select proximal area that is free from scar and local trauma, deep to muscle, in web space, or between metacarpal shafts. Dorsum preferable. 5-0 catgut suture placed in capsule (not neuroma) and tied. Tie another suture 3-4 mm away. Tunnel suture SQ and pass through skin with free needle. Tie up to dermis, with neuroma 3-4 mm from dermis. SILICONE CAPPING – Length/diameter ratio minimum 5:1, nerve cap only slightly larger. Resect neuroma, Bunnell stitch with 5-0 non-absorbable and suture out end of cap and tie. AUTHOR’S PREFERRED METHOD OF TREATMENT -For amputated nerve end or irreparable terminal branch laceration: simple resection, allowing the cut end to retract into healthy tissue. If bed inadequate, transfer the severed end. For established neuromas where distal end absent or irreparable, then relocation of intact neuroma. If the distal end of nerve is present, attempt to minimize neuroma formation by resection of the neuroma and repair of the nerve. If gap too large, then nerve graft. For amputation neuromas, then relocation. Other methods (nitrogen mustard, local radioactive materials, and silicone capping) are all interesting possibilities, but more investigation are needed. CHAPTER 47 – RADIAL NERVE PALSY -Radial nerve palsy – significant disability. Without wrist extension, unable to stabilize wrist and thumb, impairing grasp and power grip. Cannot extend digits. -Trauma usually distal to tricep branches -Imperative to differentiate between complete radial nerve palsy and PIN palsy ANATOMY -Radial nerve innervates BR & ECRL before dividing into 2 terminal branches: motor PIN and sensory PIN. Difficult to assess ECRB integrity -APM: cadaveric dissections, Henry‘s, McMinn & Hutchings atlas REQUIREMENTS IN PATIENT WITH RADIAL NERVE PALSY -Patient needs (1) wrist extension, (2) finger (MP) extension, (3) combination thumb extension and abduction -Does not need sensory – rarely a disability. Occasional anomalous sensory innervation

NON-OPERATIVE TREATMENT -Hand Therapy: PROM wrist/hand, prevent contractures -Splints: Range from dynamic outriggers to volar wrist cock-up splint. Burkhalter: grip strength increased 3-5x with wrist stabilization EARLY TRANSFER – Burkhalter and Brand advocate early end-to-side PT to ECRB transfer at time of radial nerve repair as ―internal splint‖ OPERATIVE TREATMENT -1st decision is whether to attempt nerve repair / grafting vs. tendon transfers. Late nerve repair can produce reasonably good results PRINCIPLES OF TENDON TRANSFERS -AVOIDANCE / CORRECTION OF CONTRACTURES – Maximum PROM must be present before tendon transfers -ADEQUATE / RELATIVE STRENGTH – of donor and recipient muscles. Brand: Muscle work capacity related to volume and excursion. Omer: Muscle loses one strength grade after transfer WORK CAPACITY OF FOREARM MUSCLES (Boyes) -DONOR MUSCLES (MKg): BR 1.9, PT 1.2, FCR 0.8, FCU 2.0, PL 0.1, FDS 4.8, FDP 4.5, FPL 1.2 -RECIPIENT MUSCLES (MKg): EPL 0.1, APL 0.1, EPB 0.1, EDC 1.7, EIP 0.5, ECRL 1.1, ECRB 0.9, ECU 1.1 AMPLITUDE OF MOTION -Boyes: Wrist flexors / extensors: 33mm. Finger extensors and EPL: 50mm. Finger flexors: 70mm -2 techniques to augment effective amplitude: (1) Convert mono-articular muscle to bi- or multiarticular, (2) Dissect away fascial attachments (i.e. BR) STRAIGHT LINE OF PULL -Most efficient transfer is one that passes in a direct line from its own origin to the insertion of the tendon being substituted ONE TENDON – ONE FUNCTION -Most effective if a single tendon is transferred to a single tendon SYNERGISM = finger flexors acting in concert with wrist extensors and fingers extensors acting in concert with wrist flexors. Green and Littler advocate synergistic muscle transfers: easier to retrain muscle function EXPENDABLE DONOR

-There must be sufficient muscle remaining to substitute for the donor muscle TISSUE EQUILIBRIUM -Transfer when no soft tissue induration, no wound reaction, supple joints, scars soft -Tendons pass between SQ fat and deep fascia. Tunnel gently with blunt instrument; avoid skin incision over tendon repair junctures TIMING OF TENDON TRANSFERS (controversial) -If good nerve repair done, then wait. 1 mm / day nerve regeneration (5-6 months for repair in middle 1/3 of arm) -If questionable/poor prognosis of nerve repair (gap > 4cm, skin loss / large wound over nerve) then do immediate tendon transfers and do not repair nerve (APM: Brown, Green) -No apparent time limit of successful transfers OPERATIVE TECHNIQUES (TENDON TRANSFERS) BEST COMBINATIONS OF TENDON TRANSFERS FOR RADIAL NERVE PALSY: -FCR TRANSFER SET (Starr, Brand, Tsuge): PT to ECRB, FCR to EDC, PL to EPL -SUPERFICIALIS TRANSFER SET (Boyes): PT to ECRB, FDS III to EIP and EPL, FDS IV to EDC, FCR to APL and EPB -FCU TRANSFER SET: PT to ECRB, FCU to EDC, PL to EPL APM: -FCR Transfer Set. Superficialis Set (especially if absent PL). -No PT transfer needed when PIN palsy only -Release tourniquet and achieve hemostasis before suturing transfers FCR TRANSFER SET PT to ECRB TRANSFER (if needed): Through dorsal longitudinal incision, identify PT and its insertion in volar aspect of radius. Detach its insertion with intact long periosteal strip. Free proximally and pass SQ around radial forearm, superficial to BR and ECRL to insert into ECRB, just distal to musculotendinous (M-T) junction FCR to EDC: Straight longitudinal volar incision between FCR and PL. Identify and transect FCR and PL near insertions, free to mid-forearm. Pass FCR radially SQ. Find 4 good EDC tendons and divide at M-T junctions, withdraw distally and superficial to retinaculum. PL to EPL: Identify EPL in dorsal wound, divide at M-T junction and re-route out of Lister‘s canal volarly. (If PL absent, then EPL joined with FCR-EDC transfer or do Superficial Transfer Set.) -Release tourniquet; establish hemostasis. Secure transfers with multiple 4-0 nonabsorbable sutures. Set proper tension by ―feel‖ – err on tight side. PT to ECRB (just distal to M-T junction) with wrist extended 45 degrees, maximum PT tension. PT periosteum woven through hole

in ECRB tension, reinforced with free tendon strip from ECRL. -FCR to EDC: 2 best / long EDC tendons woven into slits in FCR, 2 shorter ones sutured to long ones. Bury ends. Perform with wrist and MP joints neutral and FCR max tension. -PL to EPL: Route them in straight line and fix end-end (weave slit in EPL). Wrist neutral and max tension on EPL and PL. -Passive test: With wrist extended, fingers should easily flex into palm. With wrist volar-flexed, MP joints should fully (but not hyper) extend POST OPERATIVE CARE -Long arm splint: forearm 15-30 degrees pronation, wrist extended 45 degrees, MP 10-15 degrees flexed, thumb max extension/abduction, PIP free. Splint / sutures d/c‘d 10-14 days postop. Munster cast placed; immobilize for total 4 weeks post-op. Then hand therapy with 2 weeks removable short arm splint (wrist, fingers, thumb extended). 6 months for max recovery SUPERFICIALIS TRANSFER SET -PT to ECRB: as previously described -FDS III to EIP and EPL, FDS IV to EDC: Superficialis tendons of III and IV exposed through transverse incision in distal palm or at each finger base. Tendons divided proximal to chiasma, freed, and delivered into longitudinal volar forearm wound. Just proximal to pronator quadratus, 2 1x2 cm openings made in interosseous membrane (protect anterior and posterior interosseous vessels) -J-shaped incision on dorsal forearm – longitudinal along ulna, transverse from ulnar to radial styloids. FDS III and IV passed through interosseous membrane on either side of profundus. FDS III interwoven into EIP and EPL, FDS IV to EDC. Fixed at 20 degrees wrist extension and fist, tendons on max tension. -FCR to APL and EPB: FCR divided near insertion, freed, routed and fixed to APL and EPB. FCU TRANSFER SET -Same as FCR set, except FCU divided near insertion, freed to within 2 inches of origin (innervation site), interwoven through EDC proximal to retinaculum RADIAL NERVE PALSY ASSOCIATEDWITH HUMERUS FRACTURE -Incidence radial nerve palsy with humerus fracture is < 10 % -RX: controversial -APM: Non-operative RX, considering exploration only after adequate (5-6 months) waiting period. Most nerves spontaneously recover. Specific indications for early exploration: (1) open fracture, (2) fractures where closed reduction cannot achieve satisfactory alignment, (3) fracture with vascular injury, (4) multiple trauma. Palsy after fracture reduction is NOT an absolute indication for exploration (APM) CHAPTER 48 – MEDIAN NERVE PALSY (Davis, Barton) -Aim of reconstructive surgery in median n. palsy = restore lost motor function of thumb opposition, FPL, and FDP (index) -Median n. injuries classified as ―high‖ = proximal to origin AIN or ―low‖ = distal to AIN

-―Low‖ injuries loss = APB, OP, FPB (superficial head) -―High‖ injuries loss = ―low‖ + PT, FCR, FDS, FDP (index & middle), FPL, PQ LOW MEDIAN NERVE PALSY -Causes: (1) compression & traumatic division of median n., (2) leprosy, (3) neurologic diseases (Charcot-Marie-Tooth, spinal muscular atrophy, syringomyelia), (4) congenital absence of thenar mm., (5) Polio THUMB OPPOSITION -Prime muscle of thumb opposition is abductor pollicis brevis. Opponens pollicis and flexor pollicis brevis also produce opposition. -High variability of thenar m. innervation (ulnar n. contribution) explains why thumb abduction and opposition frequently retained after complete median n. injuries PREVENTION & PREOPERATIVE TREATMENT OF CONTRACTURES -Prevent contracture by thumb abduction / opposition exercises & abduction splints; temporary K-wire if severe soft tissue injury -If conservative treatment fails, then surgical release: dorsal web space incision, release fascia over adductor pollicis and 1st dorsal interosseous m. Widen web space with skin graft or flap. If needed, release trapeziometacarpal joint capsular contracture with incision over base of joint. If severe, rotational osteotomy of thumb metacarpal base and trapeziectomy.

OPPONENSPLASTY INSERTIONS -Abductor pollicis brevis insertion usually used (pronation occurs passively when thumb is abducted & flexed) 4 STANDARD OPPONENSPLASTIES -No universally accepted best technique SUPERFICIALIS TRANSFER ROYLE-THOMPSON OPPONENSPLASTY (FDS) – 3 cm longitudinal incision at base of palm, radial border of hypothenar eminence. Expose ulnar border of palmar aponeurosis & retract radially to identify ring finger superficialis tendon as it emerges from carpal tunnel. -Through transverse incision at base of ring finger, divide FDS & deliver into palmar wound so it passes ulnar to palmar aponeurosis. -Make 3rd incision over dorsum thumb MP joint; wide SQ tunnel made between this and palmar wound. FDS passed through this tunnel; pulley = distal edge of flexor retinaculum & ulnar border palmar aponeurosis. Attach FDS to APB insertion, splint in full opposition BUNNELL‘S OPPONENSPLASTY (FDS) -Divide ring FDS @ base of finger through transverse incision. -Incision over ulnar neurovascular bundle, just proximal to wrist. Ring FDS identified 4 cm proximal to

pisiform insertion, FCU cut halfway across and split distally to the pisiform, leaving it attached as a distally based flap to make a loop pulley. -3rd incision over dorsal thumb and widen SQ tunnel connecting it and palmar incision. FDS delivered into wrist wound, passed though pulley; through SQ tunnel, into thumb wound. -Drill hole made in thumb proximal phalanx base from dorso-ulnar cortex to radiopalmar cortex and FDS passed into this hole (superficial to EPL). Fix FDS to itself, periosteum, and/or over button with thumb in full opposition EIP TENDON OPPONENSPLASTY -Increasingly used over FDS (does not weaken grip) TECHNIQUE -Short longitudinal dorsal incision made over index MP joint & EIP divided immediately proximal to extensor hood -Long incision made on dorso-ulnar aspect of distal forearm and EIP delivered into this wound (attachments to EDC may have to cut through additional dorsal hand incisions -3rd small incision made over pisiform -4th incision over dorsoradial thumb MP -Wide SQ tunnel made from forearm to pisiform to thumb & EIP passed though it, superficial to FCU -If isolated median n. palsy, attach EIP to APB with thumb fully opposed and wrist flexed 30 degrees -If combined median / ulnar n. palsy, then attach to APB, MP joint capsule, & EPL over proximal phalanx. Immobilize as above x 3 weeks ABDUCTOR DIGITI MINIMI (HUBER) OPPONENSPLASTY -Mid-lateral incision made on ulnar border 5th digit proximal phalanx and extended proximally and radially to distal palmar crease, running along radial border of hypothenar eminence and curve in ulnarly as it crosses distal wrist crease -2 ADM insertions (base of proximal phalanx & extensor apparatus divided & ADM elevated from distal to proximal to its pisiform origin. Do not damage its dorsoradial pedicle -2nd incision made on dorsoradial aspect of thumb MP & a wide SQ tunnel made from it to just proximal to pisiform (a 3rd incision at base of thenar eminence may help) -ADM rotated 180 degrees on long axis and passed SQ & attached to APB insertion. Cast immobilization fully opposed x 4 weeks. -If need more length, consider (1) tendon graft or (2) release off pisiform, but retain attachment to FCU (however release from pisiform may endanger an already tenuous blood supply) PALMARIS LONGUS OPPONENSPLATY (CAMITZ) -Usually done when motor loss secondary to severe CTS: NOT recommended for trauma (PL usually also damaged) TECHNIQUE -Confirm PL presence preop. Longitudinal skin incision (in line with 4th ray) from 2 cm proximal to distal wrist crease to the proximal wrist crease. Do not damage palmar cutaneous branch of medina n. (which is just radial to PL) -Free PL in forearm and palm and incise 1 cm wide strip of palmar aponeurosis in continuity with PL; decompress carpal tunnel

-2nd incision made over dorsoradial thumb MP -Wide SQ tunnel made between 2nd incision and PL passed, attached to APB insertion, cast with thumb fully opposed x 4 weeks

OTHER OPPONENSPLASTIES: ECU, ECRL, EDM, AP, FPB -ECU: EPB divided at M-T junction, passed SQ across palm, attached to ECU -ECRL: EPL divided at M-T junction, re-routed SQ across palm around ulnar wrist border. ECRL divided at its insertion and sutured to EPL -EDM: EDM divided distally, re-routed around ulnar wrist border, across palm, and attached to APB -In severe combined palsies and intrinsic-minus thumb with no standard muscles available, consider FPL opponensplasty: FPL divided at insertion, IP fused, FPL re-routed around Thompson pulley, SQ palm, to FPB EPL OPPONENSPLASTY -For some cases peripheral nerve disease or spastic paralysis: syringomyelia, CMT, high median or combined injury, only functioning thumb motors are EPL, EPB, APL, (&EPL not spastic) TECHNIQUE – Through dorsal incision, EPL released distally; suture extensor hood back together. Through dorsal wrist incision, EPL withdrawn and passed in SQ tunnel around ulnar wrist border, across palm to thumb wound. Fuse thumb IP in almost full extension and some pronation (held with crossed K-wires). EPL looped around thumb at MP and sutured to itself. IP held in extension with K-wire. Cast in full opposition x 4 weeks. ALTERNATIVE EPL OPPONENSPLASTIES (Mennen, Moutet) -EPL passed through window in interosseous membrane and reattached to its own distal stump. MP not fused. POST-OP -Thumb immobilized in full opposition x 3 weeks. Wrist immobilized if tendon transfer crosses. If excursion short (i.e. EIP) wrist flexed at 30 degrees, if longer (i.e. FDS) then wrist neutral. If high combined injury or CMT or leprosy, protect for 3 months, otherwise d/c splint at 3 weeks and allow ROM APM – LOW MEDIAN NERVE PALSY -Sensation is prime determinant of hand function. Pure motor deficit is best indication for opponensplasty; rarely indicated in combined complete injuries -In practice, few patients need opponensplasty; many never lose opposition -Favor Camitz if opposition loss secondary to CTS -Other favored are EIP transfer, Royle-Thompson transfer HIGH MEDIAN NERVE PALSY

-In high median n. palsy, all flexor muscles paralyzed except FCU & FDP to ring and little fingers -Prime aim in tendon transfer: restore index and thumb flexion and opposition -Tendon transfers can restore motor function, but overall function limited by associated sensory loss -Extrinsic tendon transfers in high median nerve palsy usually only required when nerve is grafted or untreated -Most patients do not require transfers (partial ulnar innervation to thenar muscles and adaptation to other extremity for precision activity) -Some surgeons prefer early tendon transfers. Reasons: (1) eyesight can provide sensory input, (2) internal splint while nerve regenerates, (3) synergistic to recovered (if any) motor function EXTRINSIC TRANSFERS FOR THUMB FPL: BR TO FPL (end to side) -Free BR in distal 2/3 forearm. Attach end-to-side. Set tension to all 3 thumb joints can be fully passively extended with wrist flexed at 30 degrees.

FOR INDEX PROFUNDUS: FDP II TO FDP III-V (side to side) or ECRL to FDP II (end to side) FOR OPPOSITION TRANSFER: EIP TRANSFER (EPL and EDM are other options for transfer) CHAPTER 49 – ULNAR NERVE PALSY (Omer) CLINICAL PICTURE – 10 motor and sensory functions lost. MOTOR LOSS -Loss of MP flexion. If extrinsics intact, then ring & little fingers claw = Duchenne‘s sign. Also ―cross finger test‖ – failed = Earle‘s sign. -Loss of MP, IP integrated flexion. Normally MP initiates flexion, but if intrinsic paralysis, IP flexion completed first, then MP‘s flex. -Loss of key pinch of thumb because of adductor pollicis loss. -Masse‘s sign = flattened palmar arch due to opponens digit quinti paralysis and loss of little finger MP flexion. Loss of power grip. -Pollock‘s sign = Loss of ulnar FDP; inability to flex ring and little DIPs -Partial loss of wrist flexion because of paralyzed FCU -Impaired precision grip. Pitres-Testut sign = inability to bring fingertips into a cone shape. -Wartenberg‘s sign = inability to adduct the extended little finger to the extended ring finger (EDQ has slip to ulnar base of V proximal phalanx) -Jeanne‘s sign = Thumb MP joint hyperextends 10-15 degrees with key pinch or grip -Froment‘s sign (1915) = Bunnell‘s ―O‖ sign (1956) = Newspaper sign=loss of distal stability and rotation for tip pinch between thumb & index (paralysis 1st dorsal & 2nd palmar

interosseous and adductor pollicis muscle). FPL compensates & IP flexes to attempt to hold an object. SENSORY LOSS -Low (distal) ulnar nerve palsy: loss of sensation to volar little finger & ulnar-volar ring finger -High (proximal) ulnar nerve palsy: additional loss to dorso-ulnar aspect of palm and dorsal little finger ANOMALOUS INNERVATION PATTERNS -Occasionally permits the hand to have no deformity despite complete ulnar nerve lesion -Martin-Gruber Communication = communication between median nerve (or its anterior interosseous branch) and the ulnar nerve in the proximal forearm (15% occurrence). Less common distal communications also exist. -Riche-Cannieu Communication = communication from ulnar nerve motor branch to median nerve recurrent motor branch. Ulnar nerve may innervate thenar muscles. Incidence 30-80% in literature. -median nerve may innervate all lumbricals (no clawing. -3rd lumbrical has dual innervation in 50% (claw of little finger only) -1st dorsal interosseous completely or partially innervated by median nerve in 10% -Area of dorsal cutaneous ulnar nerve (6-8 cm proximal to wrist) can be supplied by superficial radial nerve, confusing the examination DIAGNOSIS -Diagnose by (1) careful voluntary muscle testing, (2) precise evaluation of sensibility and sudomotor activity, (3) anesthetic blocks of intact nerves, (4) electrodiagnostic studies TREATMENT -Options for nerve palsy: (1) nerve repair / graft, (2) tendon transfers, (3) tendon tenodesis, (4) joint arthrodesis -In high palsy, potential for motor recovery is greater than sensory recovery -Initially, splinting is important. Need to maintain transverse palmar arch & thumb-index web space APM: For low ulnar nerve injury and precise neurorrhaphy achieved, consider early internal splint tendon transfers -For patients with severe extremity injury, long nerve graft, high (proximal) ulnar nerve lesion, candidate for complete reconstruction program.

INTERNAL SPLINTS FOR LOW (DISTAL) ULNAR NERVE PALSY USING ONE PRIMARY TENDON (FDS) (WHEN FDP TOTALLY INNERVATED) (EARLY TENDON TRANSFERS) -Objectives of Early Tendon Transfer Splints: support partial function, decrease cortical exclusion, prevent deformity, stimulate sensibility re-education and improve coordination.

-NEEDED FUNCTION: Thumb adduction for key pinch. TRANSFER: Radial ½ of ring FDS to adductor of thumb. -NEEDED FUNCTION: Proximal phalanx flexion & integration of MP & IP motion for ring and little fingers. TRANSFER: Ulnar ½ of ring FDS with split insertion to ring & little fingers – either A2 pulley or radial lateral band of dorsal extensor apparatus -NEEDED FUNCTION: Metacarpal (palmar) transverse arch and adduction for little finger. TRANSFER: ―Y‖ insertion of the 2 halves of ring FDS -NEEDED FUNCTION: Thumb-index tip pinch. TRANSFER: Arthrodesis of thumb MP joint. SUPPLEMENTAL MOTOR: EPB to first dorsal interosseous DESCRIPTION OF INTERNAL SPLINT TECHNIQUES SUPERFICIALIS ―Y‖ SURGICAL TECHNIQUE (Omer) -Can improve integrated MP & IP flexion, key pinch, and metacarpal arch. Use ring FDS if its FDP is intact, otherwise use middle FDS. -Expose thumb adductor tubercle through dorsal longitudinal incision -Expose selected FDS by volar zigzag incision -Tenodese the distal radial FDS slip (as distally based flap) to proximal phalanx to prevent PIP hyperextension -Split FDS into palm; split ulnar ½ into 2 slips. These 2 slips are then inserted into ring and little fingers by 1 of 2 techniques. -Preoperatively test (Bouvier Test): Hold MP flexed & ask patient to actively extend IP‘s. If cannot, then do Dorsal Apparatus Technique. If can, then A2 Pulley Technique. -DORSAL APPARATUS TECHNIQUE: 2 FDS ¼ slips directed on radial sides of ring and little fingers volar to deep transverse metacarpal ligament and dorsally sutured to central slip insertion (through dorsal incisions over PIP‘s). Traction on slips should flex MPs and extend PIPs & correct clawing -A2 PULLEY TECHNIQUE: Gets increased power. Longitudinal zigzag incision on volar ring & little fingers. Expose proximal edge of flexor sheaths and pass FDS slips through sheath from proximal to distal & out A2, pull it proximally & suture it down. -Radial ½ of FDS directed toward thumb volar to adductor pollicis and dorsal to flexor tendons & neurovascular structures & suture into insertion of APB. Traction of slip should adduct & pronate the 1st MC & increase palmar arch. -Resting tension: wrist neutral. MP 45 degrees, PIP 0 degrees. THUMB ARTHRODESIS -If after FDS transfer, positive Jeanne‘s sign &/or when instability in longitudinal arch of thumb, then fuse thumb MP. -CHEVRON TECHNIQUE (Omer): Dorsal longitudinal approach, split apparatus between EPL & B. Chevron cut with AP apex proximal. MP flexion 10-15 degrees, pronation 15 degrees, abduction 5 degrees; hold with crossed K-wires, SATSC x 6 weeks.

PREFERRED RECONSTRUCTION PROGRAM FOR LOW (DISTAL) ULNAR NERVE PALSY -NEEDED FUNCTION: Thumb adduction for key pinch. TRANSFER: ECRB with free tendon graft between 3rd & 4th metacarpals to abductor tubercle of thumb. ALTERNATIVE TRANSFER: FDS (long) to abductor tubercle of thumb with palmar fascia as pulley -NEEDED FUNCTION: Proximal phalanx power flexion & integration of MP & IP motion for clawed fingers. TRANSFER: ECRL with 4-tailed free tendon graft passed volar to deep transverse metacarpal ligament to either A2 pulley or radial lateral band of dorsal extensor apparatus. ALTERNATIVE TRANSFER: FCR (if wrist flexion contracture) with 4-tailed free tendon graft to either A2 pulley or radial lateral band of dorsal extensor apparatus. -NEEDED FUNCTION: Thumb-index tip pinch. TRANSFER: Accessory slip of APL to first dorsal interosseous tendon. Arthrodesis of thumb MP joint. ALTERNATIVE TRANSFER: EPB to first dorsal interosseous tendon (if thumb MP arthrodesed) -NEEDED FUNCTION: Metacarpal (palmar) transverse arch and adduction for little finger. TRANSFER: EDM tendon split and ulnar ½ transferred volar to deep transverse metacarpal ligament to either radial collateral ligament of proximal phalanx or radial lateral band of dorsal extensor apparatus (EDC to little finger must be functional). ALTERNATIVE TRANSFER: If little finger is clawed as well as abducted, insert ulnar ½ of EDM into A2 pulley of flexor sheath -NEEDED FUNCTION: Volar sensibility of fingers. TRANSFER: Proximal median digital nerve translocated to distal ulnar digital nerve. ALTERNATIVE TRANSFER: Free or vascularized nerve graft PREFERRED RECONSTRUCTION PROGRAM FOR HIGH (PROXIMAL) ULNAR NERVE PALSY As above, plus: NEEDED FUNCTION: Distal finger flexion for ring and little fingers. TRANSFER: FDP (middle) tenodesed to FDP (ring & little) with tenodesis of distal IP joints in ring and little fingers -NEEDED FUNCTION: Wrist flexion-ulnar side. TRANSFER: FCR to insertion of FCU. ALTERNATIVE TRANSFER: PL to insertion of FCU DESCRIPTION OF TECHNIQUES PROXIMAL PHALANX FLEXION = Techniques to prevent MP hyperextension -Zancolli Static Primary Block Capsulodesis Technique: Open A1 pulley, retract flexor tendons. Distally based flap made from MP volar plate & sutured into metacarpal neck with MP‘s flexed to a point where IP‘s extend maximally (maximum MP capsulodesis = 30 degrees) -Omer Static Tenodesis Technique: Pass free tendon graft from ulnar lateral band of ring finger dorsal apparatus, around transverse metacarpal ligament and onto radial lateral band of little finger. Repeat for index & middle fingers. -Parks Static Tenodesis Technique: Free tendon graft placed between dorsal apparatus radial lateral band to transverse metacarpal ligament

-Riordan Static Tenodesis Technique: ECRL & ECU divided proximally & left attached distally and split longitudinally. Free ends passed volar to transverse metacarpal ligaments and sutured into radial lateral bands of dorsal apparatus with wrist 30 degrees dorsiflexed & MP‘s at 80 degrees flexion. INTEGRATED FINGER FLEXION: -Most tendon transfers designed to improved synchronous finger motion attempt to duplicate lumbricals & therefore pass volar to deep transverse metacarpal ligament & insert into lateral band of dorsal apparatus. FOWLER DYNAMIC TENODESIS TECHNIQUE – 2 free tendon grafts woven into dorsal retinaculum (or through drill holes in radius-Tsuge) & split distally. End passed volar to deep transverse metacarpal ligament & sutured to radial lateral bands with wrist 30 degrees dorsiflexed & MP‘s 80 degrees flexed. As wrist flexes, MP‘s flex & IP‘s extend. SUPERFICIALIS TRANSFER TECHNIQUES See Omer superficialis Y technique discussion WRIST-LEVEL MOTORS FOR PROXIMAL PHALANX POWER & INTEGRATION OF FINGER FLEXION Brand Technique: ECRL (or B) lengthened with free tendon grafts to 4 slips, passed superficial to dorsal carpal ligament, through lumbrical canal, volar to deep transverse metacarpal ligament & attached to radial lateral bands through dorso-radial incisions over proximal phalanges (or A2 pulleys) -Brand Modification: Lengthened ECRL passed deep to BR to volar forearm, through carpal tunnel, then distally same as above Riordan Technique: FCR elongated with free tendon graft, passed dorsally, then back palmarly, etc. (standard attachments as above) Tendon graft discussion: Plantaris absent in 8% of population. If absent, usually bilateral. U/S 95% sensitive to detect plantaris. - PL absent in11-14%. Bilateral absence - 60%. No relationship between plantaris and PL absence. THUMB-INDEX KEY PINCH & TIP PINCH -Either (1) Thumb Adduction Technique, or (2) Index Abduction Technique THUMB ADDUCTION TECHNIQUE Omer: ECRB released at insertion & extended with free tendon graft. Tunnel palmarly between 3 & 4th metacarpals and palmar to adductor policies but dorsal to flexor tendons and neurovascular structures. Attach to abductor tubercle of 1st metacarpal. (many other techniques exist)

INDEX ABDUCTION TECHNIQUE Neviaser: Transfer (elongated with free tendon graft) APL slip into tendon of 1st dorsal interosseous -Other Options: use EPB, EIP (split with 1 slip to 1st dorsal interosseous tendon and 1 to adductor pollicis), PL, FDS METACARPAL ARCH RESTORATION AND LITTLE FINGER CORRECTION Bunnell‘s ―Tendon T‖ Technique: Free tendon graft spans from thumb proximal phalanx base to neck of little finger metacarpal (dorsal to flexor tendons). FDS detached distally and looped around tendon graft Littler technique: Used FDS but no free tendon graft. 1 slip to thumb adductor tubercle, 1 to little finger proximal phalanx base. Correction of Little Finger Abduction: -EDM also inserts on abductor tubercle of little finger proximal phalanx. With ulnar nerve palsy, 3rd palmar interosseous cannot balance EDM & little finger abduction deformity may result -To correct, ulnar ½ of EDM may be transferred volar to transverse metacarcarpal ligament and to radial collateral ligament of proximal phalanx or radial band. If clawed also, insert around A2 pulley FINGER & WRIST FLEXION -If marked weakness ring and little fingers, consider attaching ring and little finger FDP to middle finger FDP in forearm (leave index FDP) -In high ulnar nerve palsy, consider transfer FCR to insertion FCU. Or PL to FCU transfer. SENSIBILITY -Consider digital nerve translocation (median innervated) to ulnar digital nerve of little finger. Results: 86% with S3+-S4. (Lewis, Stocks JHS 1991) -Free or vascular nerve graft CHAPTER 51 – BRACHIAL PLEXUS (Leffert) (see ch. 39) OPEN INJURIES -Immediate repair of stabs / sharp injury, not necessarily in middle of night, but if clean, may wait 24 hours or even delayed -If vascular injury / repair and plan on delayed nerve surgery, then tag nerves and map injury -Not all adult plexus injuries need repair / reconstruction; if minimal and tendon transfers may make quicker recovery. Repair / reconstruct all children with sharp plexal injuries GUNSHOT WOUNDS

-Assuming no pulmonary or vascular injury, local wound care initially. If no recovery in 3 months and major neurologic deficit, then explore. Also explore if causalgia and nonsympathetic pain not manageable by meds IATROGENIC INJURY -If from subclavian lines: arteriography, explore plexus if increasing pain / neurologic deficit -If from surgery of shoulder, thorax, breast and immediately recognized as from sharp injury, repair immediately. Unfortunately, usually not appreciated until patient awakens, and then difficult to differentiate if injury from traction / positioning. Wait 6 weeks then and re-evaluate -1st rib resection for TOS. Injury to lower trunk has poor prognosis CLOSED INJURIES EVALUATION (See ch. 39) -Wait 1 month before getting CT/MRI and electrodiagnostics DIFFERENTIATION OF SUPRA- AND INFRAGANGLIONIC LESION OF THE BRACHIAL PLEXUS (Evaluation technique / Supraganglionic lesion / Infraganglionic lesion) -Inspection / Flail arm, winged scapula, Horner‘s / Flail arm -Muscle testing / Paralysis of serratus anterior, rhomboids, possibly diaphragm and limbs / Paralysis of limbs -Sensation / Absent in involved dermatome / Absent in involved dermatome -Tinel‘s sign / Absent / Present (unless supraganglionic lesion at same level) -Myelography / Traumatic pseudomeningoceles, obliteration of root detail / Normal -Electromyography / Paravertebral (serratus, rhomboids) and limb denervation / Limb denervation -Nerve conduction / Motor conduction absent, may have sensory conduction / Motor and sensory conduction absent -Axon response / Normal. Absent if infraganglionic lesion is present at the same level / Absent POSTOPERATIVE BRACHIAL PLEXUS PALSY -From traction due to positioning; usually neurapraxia and resolves in 6 weeks -Avoid arm abduction > 90 degrees, excessive lateral neck flexion RADIATION INJURY TO THE BRACHIAL PLEXUS -Causes nerve degeneration, pain, and paresthesias -Difficult to assess if symptoms from radiation or tumor spread; both are progressive; positive Horner‘s usually indicates tumor; MRI may help differentiate; sometimes need to explore for diagnosis -RX not resolved. Options: neurolysis +/- pedicle or free omental wrapping (to revascularize). May help with pain but not neurologic function TECHNIQUE OF OPERATIVE TREATMENT OF THE BRACHIAL PLEXUS (also see ch. 39) GENERAL CONSIDERATIONS AND EQUIPMENT -Patient must be able to tolerate 8-10 hours of general anesthesia

-Blood must be available for transfusion INTRAOPERATIVE MONITORING -Need anesthetic without total paralysis -Need SSEPs (Somatosensory-evoked potentials) SURGICAL APPROACH (see ch. 39) RECONSTRUCTION OF THE UPPER EXTREMITY IN PATIENTS WITH IRREPARABLE INJURIES TIMING -Wait 1-2 years if no plexal reconstruction, 2-3 years if reconstructed SHOULDER RECONSTRUCTION -Although some authors transfer trapezius, APM is to fuse the shoulder if total loss of shoulder control and transfers not possible. Must save trapezius and serratus anterior function. If these scapular motors are deficient, then leave flail unless painful inferior subluxation uncontrollable by prosthesis -For pediatric population with obstetric palsy where shoulder not subluxed, consider L‘Episcopo procedure, where latissimus dorsi and teres major insertions are transferred posterolaterally to enhance lateral rotation SHOULDER ARTHRODESIS TECHNIQUE -Pelvic recon plate over scapular spine and acromion down proximal humerus and long lag screws into decorticated GH joint (3-5 70-85 mm 1/3 - ½ threaded cancellous screws with washers) -Lateral decubitus position, posterior approach -Incision parallel to and 1 fingerbreadth inferior to scapular spine, anterolaterally across acromion down midlateral humeral shaft 10 cm -Fusion position: 20-30 degrees GH abduction, 30 degrees forward flexion, 30-40 degrees internal rotation -Decorticate GH joint -Lag screws should penetrate dense subchondral glenoid neck; avoid going out scapula (pneumothorax). If sudden drop in O2 saturation, assume pneumothorax and get CXR; insert chest tube through same field -Use local bone graft -Bolster splint post-op; spica cast when patient can stand (x 6 weeks) -Shoulder pain (from nerves) may persist RESTORATION OF ELBOW FLEXION -APM: prefers tendon transfers if partial lesion and sensory function remains in radial hand. Need PROM in functional arc. -APM: pectoral transfer (need normal or fused shoulder). 2nd choice (or woman): modified Steindler flexorplasty, triceps transfer (if no other alternative) -Other transfers: latissimus transfers (problem is common innervation C5-7 as elbow flexors)

STEINDLER FLEXORPLASTY -<5 pounds power -Must have normal PT / wrist flexors TECHNIQUE (Mager and Green: modified Steindler, JBJS, 1954) -Curvilinear incision: starts 7.5 cm proximal to elbow, anteriorly; curves posterior to medial epicondyle; curves anterior again distally 10 cm over pronator teres -Raise full thickness flap -Mobilize ulnar nerve; preserve FCU branch -Incise pronator teres fascia and identify median nerve; preserve the PT branch, which is 1.5-5 cm proximal to elbow -Detach common origin of PT/wrist flexors with a fragment of bone from the medial epicondyle (0.5 – 0.75 cm thick); distally strip muscles until with elbow flexed 130 degrees, the origin can be advanced 5-7 cm proximally -Make a circular trough and fix the transfer either with #5 ethibond through a short anterior bony tunnel or suture anchor -Posterior splint elbow at 130 degrees x 4 weeks, then ROM (do not attempt to overcome the expected 30 degrees flexion contracture) PECTORALIS MAJOR TRANSFER -Shoulder must be normal or fused -Muscle pedicle elevated off the chest wall with its nerve and vessels intact, routed SQ down the arm and inserted into the biceps tendon at the elbow -Post-op as in Steindler WRIST -If 2 tendons not available for wrist flexion/extension, then fuse (see ch. 6) HAND -See ch. 47-50 -Hand should generally be reconstructed 1st. Especially regarding shoulder fusion, limb positioning would otherwise be difficult THE DILEMMA OF THE FLAIL-ANESTHETIC ARM Choices: -Functional bracing. Shoulder must be locked and patient must be able to flex elbow -Amputation, especially if irreparable vascular injury. If no shoulder control, then fuse. Retain elbow if proprioception intact BIRTH PALSY = OBSTRETRIC BRACHIAL PLEXUS INJURY See ch. 39 -C5-6 = Erb‘s palsy -C8, T1= Klumpke‘s palsy LATE DEFORMITIES AND RECONSTRUCTION

-Shoulder may be contracted adducted and internally rotated. Important to stretch. Consider anterior release and L‘Episcopo (see ch. 39) -Posterior subluxation of radial head -Supination contracture: consider Zancolli (JBJS, 1967) reconstruction: release proximal and distal radioulnar joints and interosseous membrane; z-lengthen biceps, detach and re-route posterolaterally (changes it to a pronator) -Usually wait until child is 4-5 years old, understands surgery and goals

PATIENT SELECTION AND CLASSIFICATION -Patient selection is most important factor in determining success -Frequently little relationship between level of skeletal lesion and spinal cord lesion -Lesions may be asymmetric -May be unusual patterns of sparing of sensory and motor SENSORY CLASSIFICATION -2 categories: 1) O for ocular or visual input (2 point discrimination on thumb > 10mm); patient depends on vision for afferent information and grip control; 2) Cu for cutaneous afferent input (2 point discrimination on thumb < 10mm) MOTOR CLASSIFICATION INTERNATIONAL CLASSIFICATION FOR SURGERY OF THE HAND IN TETRAPLEGIA -Defined into groups based on which muscles are intact (at least Grade 4/5 MRC) -With higher number group, previous functions also intact - GROUP 0; Motor – None below elbow; Function – Elbow flexion and supination - GROUP 1; Motor – BR; Function – - GROUP 2; Motor – ECRL; Function – Wrist extension (weak or strong) - GROUP 3; Motor – ECRB; Function – Wrist extension - GROUP 4; Motor – PT; Function – Wrist pronation and extension - GROUP 5; Motor – FCR; Function – Wrist flexion - GROUP 6; Motor – Finger extensors; Function – Extrinsic finger extension (partial or complete) - GROUP 7; Motor – Thumb extensor; Function – Extrinsic thumb extension - GROUP 8; Motor – Partial digital flexors; Function – Extrinsic finger flexion (weak) - GROUP 9; Motor – Lacks only intrinsics; Function – Extrinsic finger flexion - GROUP X; Motor – Exceptions; Function – TIMING OF OPERATIVE TREATMENT -Serial sensory and motor testing at 3 month intervals; wait at least 1 year before considering surgery -Wait until neurologic improvement has stopped before considering surgery

ROLE OF SPASTICITY -Muscles with uncontrolled spasticity should not be transferred GOALS OF OPERATIVE TREATMENT -Improve function DEVELOPMENT OF THE SURGICAL TREATMENT PLAN -Make sure all organ systems (cardiopulmonary, urogenital) are addressed -Address skin (pressure sores) issues -If symmetrical involvement, then start with dominant extremity -If asymmetrical, then start with side with better function CONTRAINDICATION TO OPERATIVE TREATEMENT -Spasticity -Psychoneurosis ELBOW EXTENSION -First function to attain operatively -Helps with transfers, independence. Allows to reach for items. -Helps improve function of transferred BR DELTOID TO TRICEPS TRANSFER (Moberg) -If deltoid spared BICEPS TO TRICEPS TRANSFER FOREARM PRONATION -Reroute biceps around the radius in opposite direction. Bring hands out of supination. PROCEDURES ACCORDING TO CLASSIFICATION 3 MAIN PHASES OF RECONSTRUCTION 1. Lateral – key pinch 2. Finger flexor/extensors 3. Ulnar nerve reconstruction GROUP 0: No motor below elbow -Few patients qualify for transfer -Consider orthosis powered by an external source: ―CO2 muscle‖ or electric motor or functional electrical stimulation GROUP 1: Strong BR -BR to ECRB/L transfer: provides sufficient wrist extension to operate a wrist driven flexor hinge splint, or to consider a Moberg‘s Simple Hand Grip (Key Pinch) Procedure MOBERG‘S SIMPLE HAND GRIP (KEY PINCH) PROCEDURE

-Needs strong wrist extension -Release thumb pulleys to allow bowstringing -Dorsal tenodesis of thumb extensor hood MP mechanism to prevent MP hyperflexion -Thumb IP fusion -Divide ECRL/B retinaculum to allow bowstringing -Tenodese FPL to volar radius through bony tunnel GROUP 2: Strong ECRL -Consider Moberg‘s Simple Hand Grip (Key Pinch) Procedure GROUP 3: Strong ECRB (&ECRL) -Clinical Test (Bean JBJS 1992): With elbow 90 degrees, extend wrist against resistance. If ECRL & ECRB are both Grade 4 to 5, then discernible groove can be palpated between muscle bellies -Leave ECRB (more central) and transfer ECRL -Can either perform simple solution: Moberg‘s Simple Hand Grip (Key Pinch) Procedure, or more complex Zancolli Two-Stage Reconstruction (transfers BR & ECRL) ZANCOLLI TWO-STAGE RECONSTRUCTION STAGE I FINGER EXTENSION TENODESIS -Dorsal incision, suture EDC together, make 2 x 2 cm ulnar based periosteal flap, make sideways horseshoe-shaped cortical slot with 3-mm drill bit and osteotomes to put EDC under cortex and suture THUMB EXTENSION & ABDUCTION TENODESIS -Strip of APL divided at musculotendinous junction, brought through 3rd compartment, both APL and EPL sutured to themselves around Lister‘s tubercle INTRINSIC TENODESIS TO PREVENT OR REDUCE CLAW DEFORMITY -―Lasso‖ Operation: Transverse or Bruner incision at MP crease, exposing A1 & A2 pulleys. 2 slips FDS identified and divided as far distally as possible, brought between A1 & A2 and sutured to itself. THUMB IP FUSION TO STABILIZE STAGE II -ECRL transferred to FDP end to side -BR to FPL -If thumb MP, capsulodese volar capsule to bone GROUP 4: Strong PT -PT to FCR transfer (Zancolli) -or PT to FPL GROUP 5: Strong FCR HOUSE‘S 2-STAGE RECONSTRUCTION FOR GROUP 5 STAGE I (EXTENSOR PHASE) -CMC Fusion: 20 degrees extension, 40 abduction, 10 pronation

-APL & EPL Tenodesis (see above) -EDC Tenodesis (see above) or BR to EPL & EDC Transfer -Intrinsic Tenodesis with Free Tendon Graft (if significant IP lag): Free tendon graft routed through the lumbrical canals, beneath the deep transverse metacarpal ligament, around the 2nd (or 4th) metacarpal, sutured radially into lateral bands and central slips of each finger STAGE II (FLEXOR PHASE) -ECRL to FDP -PT to FPL -Thumb IP Fusion if hyperflexes after FPL transfer (or transfer ½ of FPL to EPL distally)

GROUP 6: Strong finger extensors, but weak EPL -Tenodese EPL to EDC GROUP 7: Strong thumb extensor GROUP 8: Partial digital flexors ZANCOLLI 2-STAGE RECONSTRUCTION FOR GROUPS 7 & 8 STAGE I -FDP all united -BR to FPL transfer STAGE II -Opponens transfer to abduct thumb: with FCU routed through ½ FCU loop, extended with tendon graft -―Lasso‖ procedure activated with ECRL to FDS transfer GROUP 9: Lacks only intrinsics -Only needs stage II from above GROUP X: Exceptions Chapter 53 – Open Hand Injuries (Brown) ASSESSMENT HISTORY -―When‖- After 6 hours, closure becomes progressively more dangerous -―Where‖ – kitchen vs. barn -―How‖ EXAM -Circulation: White hand or digit implies arterial impairment. Blue color implies venous stasis. -Bone: obtain x-rays

-Tendons: Suspect severed extensor tendons in dorsal wounds, even if finger extension possible. Test flexors, finger position, and passive test. -Neurologic: Sharp/dull, 2 point, Semmes-Weinstein. TREATMENT RESTORATION OF BLOOD FLOW-the highest priority -Perfusion may be impaired from severed or occluded arteries or restricted egress from venous congestion with potential for compartment syndrome. -Major arteries should be repaired. Venous repair seldom required. Consider compartment release of forearm, carpal tunnel, hand. CARE OF THE WOUND -Bacterial counts of >100,000 / gram tissue will interfere with healing DEBRIDEMENT-first and most important surgical act -Cleanse and excise. Use pulse lavage at low, use at least 2L for large wound. No benefit to adding antibiotics in irrigant. Excise contaminated and nonviable tissue. Excise bone fragments that are completely free of soft tissue attachment and replace later by bone graft if needed. Skeletal framework can be maintained by K-wires. Initial appearance of battered tendons and nerves can be deceptive; don‘t debride too early. Release tight compartments. SECOND LOOK -2nd look (and sometimes 3rd, 4th) for redebridement and further repair may be needed. When in doubt, leave open. INDICATIONS FOR AMPUTATION -Amputate parts that would hamper or have no useful function, be grotesque or painful. If in doubt, preserve and may be removed later. SKELETAL STABILITY -4 R‘s of fracture management: recognition, reduction, retention of reduction, restoration of function. If gaps and defects, reconstitution replaces reduction and retention. -K-wires (0.045-inch most common) can be used for almost any setting: transcortical, IM, springy bayonet to span gaps, transfixion to adjacent stable bones. Newer mini-fragment systems are being used-require wider exposure and are technically demanding. DEEPER STRUCTURES (vessels, tendons, nerves, ligaments, cartilage, bone) -Contrary to popular belief, these do not have to be covered immediately. Exposure itself is not harmful; it is the drying out that may cause irreversible damage. If kept moist by proper dressings, exposure can be tolerated for many days. DEFINITIVE SKIN CLOSURE AND COVERAGE -Save all skin and soft tissue -If wound is clean and open less than 6 hours, consider primary closure and healing by primary intention -If closure delayed a few days = delayed primary closure -If severe contamination, leave open allow to heal by secondary intention -When in doubt, middle course is loose closure with steri strips (no benzoin). Approximate wound edges and control flap distortion. -Avoid pressure from patient and ER to close contaminated wounds. ―Experience in past wars has convincingly demonstrated not only that wounds of the hand may be safely left open, but that many will do better that way.‖

-Also, do not cover a contaminated wound with primary skin graft or flap. Wait until it is clean! DRESSINGS -Dressing functions: keep tissues moist, prevent contamination, maintain circulation by edema prevention. Wound covered with fine mesh gauze with light petrolatum (or saline). Hand in safety position. ANTIBIOTICS AND TETANUS PROPHYLAXIS -Treat with antibiotics if infection risk moderate. Culture at time of debridement. Tetanus prophylaxis is required for all but the most trivial open hand wounds. TETANUS WOUND CLASSIFICATION -(1st listed is tetanus-prone / 2nd is nontetanous-prone): -Age of wound (>6 hours / <6 hours) -Configuration (stellate, avulsion, abrasion / linear) -Depth (>1cm / <1 cm) -Mechanism (Missile, crush, burn, frostbite / sharp surface) -Signs of infection (Present / Absent) -Devitalized tissue (Present / Absent) -Contaminants: dirt, feces, saliva (Present / Absent) -Denervated or ischemic tissue (Present / Absent)

TETANUS IMMUNIZATION SCHEDULE -Td=Tetanus and diphtheria toxoids (if >7 years old, Td better than just tetanus toxoid. If < 7 years old, then give DTP (DT if pertussis vaccine contraindicated)) -TIG=Tetanus immune globulin (human) -History of Adsorbed Tetanus Toxoid (doses): Unknown or < 3. For tetanus-prone wounds, need both Td (or DTP if < 7 years old) and TIG. If nontetanus-prone wound, just need Td (or DTP). -History of Adsorbed Tetanus Toxoid (doses): > 3. For tetanus-prone wounds, only need Td (or DTP if < 7 years old) if more than 5 years since last dose. If nontetanus-prone wound, only need Td (or DTP if < 7 years old) if more than 10 years since last dose. SPECIFIC INJURIES ABRASIONS=split thickness skin loss where enough deeper layers exist to fully regenerate the lost tissue. RX: Cleanse, leave open to air or dry dressing. If need reconstructive surgery, wait until reepithelizlized or surgical scrub to decrease high bacterial counts. AVULSION=skin loss where stratum germinativum has been lost. LACERATIONS – important to examine to determine and address deeper structures CRUSH AND BURST – follow principles AVULSION AND DEGLOVING: DORSUM OF HAND – If intact paratenon, then STSG when clean. If tendons mangled, then flap (that has subdermal fat and areolar tissue) when clean (around 9th day-ROM in interim),

then either intercalary tendon grafts or transfer. For distally based flaps, clean and replace flap with steri strips, examine in 3 days to assess viability. PALM OF HAND – Full thickness avulsion usually from FOOSH. Heals well by secondary intention. Encourage active use of hand while healing. FINGER DEGLOVING – If N/V avulsed, consider amputation; repair and skin grafts do not do well. AMPUTATION – ―In most cases, completion amputation is best course.‖ See replantation chapter for replant indications. MACHINE MANGLING – Follow principles. Grease and lubricants are far less dangerous than soil and vegetation from lawn or farm. Skeletal realignment and stabilization best done at initial operation. PENETRATION, INJECTION, AND BITES – If wound from clean knife or other intact sharp object and deeper structures are intact, then just thorough lavage. If glass or organic object penetrated, then need exploration for retained material. If pressure injection injury, need wide open debridement. If animal (including human) bite, need open I&D, Abx, leave open. GUNSHOT WOUNDS – follow principles EXPLOSION AND BLAST – follow principles CHAPTER 54 – COMBINED INJURIES (Buchler, Hastings) GENERAL TREATMENT PRINCIPLES: -DEBRIDEMENT -FASCIOTOMY -BONE / JOINT STABILIZATION – As rigid as possible. Goal: Immediate motion post-op. Bone: Do not shorten in fingers > 5 mm, metacarpal > 1 cm. Joint: If joint unrepairable, consider silicone rubber prosthesis. -REVASCULARIZATION – May need vein grafts -MUSCLE / TENDONS – Limits of direct suture gaps: thumb 1 cm, finger 1.5 cm. If gaps exceeded, then consider tendon grafts or transfers. -NERVES – May need to graft -SOFT TISSUE – May need flaps. Devascularized avulsed skin may be defatted, stabbed for drainage, and replaced as full thickness skin graft over well-perfused tissue. DRAINAGE – Need good drainage POST-OP – Steroids occasionally used under special circumstances (i.e. massive crush where excessive swelling anticipated). Immediate ROM important (even if nerve / vascular grafts done) -Consider joint arthrodesis (especially finger CMC‘s, thumb MP) -Consider amputation if needed (finger or ray) followed by later reconstruction if needed FOREARM -Moderate skeletal shortening (3-5 cm) acceptable. Need to maintain relative length between radius and ulna. If major diaphyseal segment missing, consider: (1) bone graft, (2) one bone forearm

-May need long (saphenous) vein graft

-Rheumatoid arthritis is a systemic condition affecting synovial tissue -Rheumatoid synovium destroys articular cartilage buy a poorly understood enzymatic reaction, invades subchondral bone, and stretches soft tissues the support the involved joint. It surrounds and invades the flexor and extensor tendons. Usually symmetric. SURGICAL CONSIDERATIONS IN THE ARTHRITIC PATIENT -Hand reconstruction does not restore normal function to rheumatoid hands -Pain may be alleviated, deformity corrected, function improved, but motion and dexterity will be limited and weakness will remain -Treatment requires a coordinated effort between the rheumatologist, orthopaedic surgeon, and physical, occupational, and hand therapist -Nearly all surgical procedures fall into 1 of 5 groups: synovectomy, tenosynovectomy, tendon surgery, arthroplasty, arthrodesis. -In general, synovectomies are indicated for mild disease controlled by drugs who have persistent synovitis in 1-2 joints. Synovectomies contraindicated if rapidly progressive joint disease -Early tenosynovectomy may be required in rapidly progressive disease to prevent tendon rupture -Be cautious with patients with mild deformity who are basically healthy and active but who are frustrated because of loss of function. Hand surgery cannot restore full function in these patients and may weaken the hand -Hand surgery can also be disappointing in patients who have significant deformity but minimal pain and relatively good function -Deformity likely to recur following surgery MEDICAL CONSIDERATIONS IN THE RHEUMATOID PATIENT -Evaluate cervical spine pre-operatively: (1) history of numbness/paresthesias, (2) cervical spine x-ray to R/O instability (general anesthesia considerations) -Temporomandibular joint involvement (general anesthesia considerations) -Pulmonary involvement (rheumatoid nodules or interstitial fibrosis) -Felty‘s syndrome (=RA, splenomegaly and neutropenia) can have decrease WBC and increased susceptibility to infection -Drugs: Steroid and penicillamine can delay wound healing; methotrexate can affect liver. Gold, penicillamine, and methotrexate can suppress platelet counts, ASA affects platelet function. Be cautious with narcotic use. HAND SURGERY PRINCIPLES -Priorities for hand surgery: (1) alleviate pain (foremost goal), (2) improve function, (3) retard disease progression, (4) improve appearance

-Consider concomitant carpal tunnel release (surgery can aggravate undetected carpal tunnel syndrome) -MP deformities should usually be corrected before PIP (except in boutonniere deformity) -Reconstruct MP joints before extensor tendon reconstruction -If needed, shoulder/elbow reconstruction should be done before hand reconstruction -Consider lower extremity problems and ambulatory aids are needed; may need fusions. Also consider simultaneous hand and foot surgery by 2 teams OTHER CONNECTIVE TISSUE DISEASES (RHEUMATOID VARIANTS) -Psoriatic arthritis, systemic lupus erythematosus, scleroderma frequently involve the hand and wrist PSORIATIC ARTHRITIS -A rheumatoid variant, seronegative spondyloarthropathy. Arthritis is asymmetric. -Classic finding: scaly, erythematous skin rash. 80% have nail changes: pitting, leukonychia, crumbling. 5% psoriatic patients have arthritis -Skin lesions usually preceded arthritis -Higher infection risk post-op (Staph a.) -Ultraviolet light improves rash. -Radiographic osteolysis and ―pencil-in-cup‖ changes: joint with tapered proximal side and bone proliferation on the distal side. Joints with a combination of osteolysis and auto-fusion -Arthritis mutilans in its most full-blown stage, collapse of digits=―opera glass hand‖ -Inflammation of periosteum, tendons contributes to ―sausage digits‖= ―psoriatic dactylitis‖=fusiform swelling. Best treated with medicines. DIGITAL DEFORMITY -PIP flexion deformity. Fuse severe deformity -MCP hyperextension deformity, may require arthroplasty -DIP tend to auto-fuse and not require surgery. -Treat arthritis mutilans with early joint fusions THUMB DEFORMITY -Most common deformity: MCP flexion and IP hyperextension -Surgical procedures: MCP/IP fusions, CMC resection arthroplasty with ligament suspension WRIST DEFORMITY -fusion and distal ulna excision SYSTEMIC LUPUS ERYTHEMATOSUS (SLE) -Multisystem disease involving several organs: heart (pericarditis), lungs (pleuritis), kidneys. -Skin: butterfly-shaped rash on cheeks and across bridge of nose, rash on fingers and palms -Diagnosis of SLE: 4 of 14 criteria (i.e. LE cells, arthritis, Raynaud‘s disease, facial erythema, pleuritis, pericarditis, uremia) -9:1 female to male ration, average age between 15-25 years -Hand involvement: symmetric joint swelling, pain/stiffness, deformity (laxity, tendon subluxation, but not joint destruction)

-SLE requires team management. Medical issues take priority over hand issues. Initial treatment without major organ issues is with NSAIDs. Corticosteroids indicated in more serious disease. -Initial treatment of correctable hand deformity: exercise and splinting WRIST DEFORMITY -May require limited or total wrist fusion. APM: longitudinal Steinmann pin fixation. -Darrach procedure for symptomatic dorsal subluxation of ulna; bevel the dorsal lip and stabilize with ECU MCP DEFORMITY -Subluxation of extensor tendon ulnar to metacarpal head caused proximal phalanx top sublux volarly and ulnarly deviate. Ulnar intrinsic shortens and PIP hyperextends -Treatment (APM): Dorsal approach, joint capsule defect repaired, extensor tendon relocated to dorsum of joint to bone, contracted ulnar sagittal fibers step-cut and lengthened. High recurrence rate: may require silicone arthroplasty. PIP DEFORMITY -Soft tissue procedures for mild deformity, fusion for severe, fixed deformity THUMB DEFORMITY -If passive MCP extension possible, then EPL re-routing if IP or CMC need fusion. Reef collateral ligaments, K-wire, and splint x 6t weeks. -If MCP is fixed, unstable/dislocated and CMC/IP good, then fuse in 15-20 degrees flexion -If MCP/IP fused, then CMC resection arthroplasty/anchovy SCLERODERMA=systemic sclerosis/fibrosis of connective tissue and small blood vessels -Generalized disease of skin, GI, kidney, lungs, heart. More frequent in females. Etiology is unknown. -Skin fibrosis affects hand leading to deformity and function loss. Also contracted skin around the mouth impedes its opening; patients look alike. -Common features: CREST- Calcinosis (subQ hard painful areas), Raynaud‘s, Esophageal dysfunction, Sclerodactyly (thin, shiny fingers), Telangectasia DIGITAL DEFORMITY PIP -PIP flexion contracture most common, skin can break down. Web space contracted. -Splinting/exercises unlikely to stop progression -If fixed contracture, arthrodesis is procedure of choice MCP -If MCP motion reduced, then regain with capsulotomy or arthroplasty -If fixed MCP hyperextension, consider metacarpal head resection DIP -Surgery of DIP either fusion or if uncontrollable infection, amputation FIRST WEB CONTRACTURE -May require adductor release and skin grafting ULCERATION: Initially splint and wound care with Silvadene. Antibiotics if infected. Surgical options: resection of bony prominence, fusion, or amputate CALCINOSIS: Surgically remove if painful

VASCULAR INSUFFICIENCY -Decrease sympathetic innervation by digital artery adventitial stripping, interposition vein grafting any occlusions, releasing constrictive bands around vessels. RHEUMATOID NODULOSIS -Common in RA; occasionally in SLE -Most commonly in olecranon, extensor forearm, dorsal hand. -may cause erosion and drain -Symptomatic nodules may be resected, but tend to recur RHEUMATOID ARTHRITIS = Systemic and soft tissue disease. Hypertrophic synovitis can destroy cartilage, compress or rupture tendons, compress nerves, erode and dislocate joints. -Look at beginning of chapter for general information -Wrist and MP joints most often affected -PIP joints can be involved with Sjogren syndrome (associated with dry eyes/mouth) -RA patients frequently also with de Quervain‘s, carpal tunnel syndrome, trigger digits. -Helpful surgical axiom is to start proximally and work distally, alternating fusion with motionsparing procedures. TENOSYNOVITIS -3 common sites of tendon sheath involvement: (1) dorsal wrist, (2) volar wrist, (3) volar digits. -Causes pain, dysfunction, tendon rupture. TENOSYNOVITIS OF THE DORSAL WRIST -Present within swelling (may be painless). Small fibrinoid ―rice bodies‖ may fill the tendon sheaths. -Initial treatment with drugs, rest, possible local cortisone injection may result on remission. -Dorsal tenosynovectomy indicated if no improvement after 4-6 months of medical management TECHNIQUE OF DORSAL WRIST TENOSYNOVECTOMY -Straight longitudinal incision made over dorsal wrist, preserve nerves and longitudinal veins. -Longitudinal incision into 6th compartment, retinaculum opened as a single, radial based flap. As each compartment is opened, vertical septum is divided. -Remove hypertrophic synovium from each tendon sheath -Repair frayed tendon with interrupted sutures; if tendon rupture appears imminent, then suture to adjacent extensor tendon above and below the damaged area -If wrist joint with synovitis, then open joint and perform synovectomy and remove bony spicules. Perform distal ulna resection if dislocated and prominent -1/2 of the dorsal retinaculum is passed deep to the tendons. -Drain post-op to avoid hematoma TENOSYNOVITIS OF THE VOLAR WRIST -Impaired active and passive digital motion -Early decompression of the carpal canal (to prevent permanent median nerve damage) is combined with flexor tenosynovectomy TECHNIQUE OF VOLAR WRIST TENOSYNOVECTOMY

-Examine and know function of flexor tendons preop -Palmar incision is made (as in carpal tunnel release) and extended proximally above the wrist crease 4-5 cm in a zigzag manner. Protect the palmar cutaneous branch. Transect the transverse carpal ligament to open the carpal tunnel. -Perform synovectomy and free the tendons and median nerve. -Look for damaged tendons -Inspect floor of carpal canal, remove bony spicules -Pull on tendons to look for triggering; release as needed DIGIT FLEXOR TENOSYNOVITIS -4 clinical patterns of rheumatoid ―trigger finger‖: Type I: resembles triggering of nonrheumatoid stenosing tenosynovitis, Type II: flexor tendon nodules in distal palm causing finger to lock flexed, Type III: nodule in FDP in region of A2 pulley causing finger to lock in extension, Type IV: generalized tenosynovieis with limited digital motion -TREATMENT: flexor tenosynovectomy and excision of flexor tendon nodules for all types DIGITAL TENOSYNOVECTOMY TENDON RUPTURES -Cause and location vary -Attritional ruptures occur as the tendon moves across bone roughened or eroded by chronic synovitis -Most frequently occur dorsally at distal end of ulna or Lister‘s tubercle, and palmarly at scaphoid tubercle. -Treatment options: fusion or tendon transfers -Tendon transfer issues in RA: 1) joints may be stiff or unstable, 2) bed may be scarred, 3) tendons to be transferred may be weak, 4) may not be able to rely on tenodesis if wrist, MP, PIP joints stiff DIAGNOSIS -Sine qua non is sudden loss of finger extension or flexion. Usually painless and commonly follows trivial activity EXTENSOR TENDON RUPTURES -Usual progression of extensor tendon ruptures star ulnarly and progress radially. VaughnJackson Syndrome = rupture of EDC of ring and small finger secondary to caput ulna. -3 conditions can mimic tendon rupture: 1) MP dislocation, 2) subluxed extensor tendons, 3) PIN compression from elbow synovitis. SPECIFIC EXTENSOR TENDON RUPTURES EPL RUPTURE -Patient can usually extend the IP by intrisics, but cannot hyperextend (EPL function). Specific test for EPL: palm flat on table, active extension of thumb and palpate EPL -Treatment options: end to end repair, tendon graft, tendon transfer (EIP or ECRL). APM: EIP transfer: Identify EIP at MP level (ulnar of 2 tendons), transect and withdraw at wrist through 2nd incision, pass SQ to thumb and weave in EPL. Tension: thumb extends with wrist flexion, able to flex to small finger pulp with wrist extended.

SINGLE FINGER EXTENSOR RUPTURE -End to end direct repair occasionally feasible -If direct repair not feasible, then suture to adjacent tendon. Perform tenosynovectomy and remove offending bony structures. May transfer 50% of extensor retinaculum volar to tendon to cover bone if needed. Tension: fingers extended with wrist flexion, MP‘s flex 30 degrees with wrist extension. MULTIPLE TENDON RUPTURE RING AND SMALL FINGERS -EIP transfer to small finger, distal stump of ringer finger sutured to long finger tendon RUPTURE OF MORE 3 TENDONS (small, ring, long) -Long finger FDS transferred subcutaneously radially (or through interosseous membrane) to ring and little finger. Long finger extensor sutured to index finger extensor tendon. Needs 3 incisions. RUPTURE OF EXTENSOR TENDONS (all fingers) -Ring finger FDS transferred subcutaneously radially to ring and little finger. Long finger FDS transferred to long and index finger. TENDON TRANSFERS IF WRIST IS FUSED -May use wrist flexors and extensors; usually need intercalary grafts MULTIPLE RUPTURES WITH MP JOINT DISEASE -Either staged reconstruction (MP arthroplasty first, then tendon transfers), or single procedure FLEXOR TENDON RUPTURES -Less common than extensor tendon ruptures -Most common flexor rupture is FPL. FPL is eroded by volar osteophytes on scaphoid = Mannerfelt Lesion FPL-Carpal tunnel incision, extended proximal to wrist crease. Remove bony spicule of scaphoid. Restore FPL with intercalary graft (PL, 1/2 FCR, or APL slip) or tendon transfer (long finger FDS to pull-out suture over distal phalanx). FDS FDS & FDP THE WRIST NATURAL HISTORY -―Caput ulna syndrome‖: synovitis stretches the ulnar carpal ligamentous complex with resulting dorsal dislocation of the distal ulna, supination of carpus on the forearm, and volar subluxation of the ECU. Symptoms: pain and weakness. Exam: Prominent distal ulna, DRUJ instability, radial deviation of wrist, possible ECU rupture.

-Radiocarpal synovitis may destroy carpal ligaments, leading to RSS and eventual wrist translocation ulnarly WRIST SURGICAL PROCEDURES: Either preventive (joint synovectomy, wrist extensor balancing, tenosynovectomy), or reconstructive (distal ulna resection, UC ligament reconstruction, total wrist arthroplasty, partial wrist fusion, total wrist fusion) SYNOVECTOMY OF RC JOINT AND DRUJ INDICATIONS: Not clearly established. No studies conclusively show that synovectomy changes the natural history. One approach is to do it if persistent, painful synovitis and minimal to moderate x-ray changes. DORSAL WRIST SYNOVECTOMY Dorsal approach through the 4th or 6th compartments. PIN neurectomy (radial aspect of 4th compartment floor). Transverse or distally based ―U‖ capsulectomy. Synovectomy, curette cysts. Expose DRUJ just proximal to TFC and debride. Close capsule. Tenosynovectomy. Long arm splint in 45 degree supination for 4-6 weeks. VOLAR WRIST SYNOVECTOMY Carpla tunnel incision, transverse capsulectomy. Debride synovium. DISTAL ULNA RESECTION AND DRUJ RECONSTRUCTION Dorsal approach between 5th and 6th dorsal compartments. Watch for dorsal branch ulnar nerve 1 cm distal to styloid (but may have branches 6cm proximal). Subperiosteal dissection, resect distal ulna just proximal to DRUJ, dorsally bevel ulna. Synovectomy DRUJ. Reconstruct ECU from volar to dorsal (may need sling of extensor retinaculum). 2 methods (of many) to stabilized distal ulna: 1) distally based ½ ECU tenodesed to distal ulna through dorsal hole and sutured to itself. 2) Pronator quadratus transferred to dorsal ulna and ECU sheath. Long arm splint in 45 degrees supination. TENDON TRANSFERS TO BALANCE WRIST (If supple deformity. If fixed deformity, needs fusion) ECRL TO ECU TRANSFER: Indicated if radial deviation deformity is passively correctable, which is not the usual case. Usually patients have a fixed deformity. ECU REPOSITIONING: Reposition ECU to its anatomic position, and hold with a loop of retinaculum RC JOINT Indications for surgery: persistent pain unresponsive to medicines, deformity and instability with loss of function. OPERATIONS FOR THE RHEUMATOID WRIST TOTAL WRIST ARTHROPLASTY: Indications: Low demand patient, functional ROM, good bone stock, functioning wrist extensors, minimal wrist deformity

WRIST FUSION: Indications: High demand patient, poor bone stock, poor wrist extensor function, significant wrist deformity, ulnar translocation of carpus TECHNIQUES: 1 large Steinmann pin from between 2nd /3rd or 3rd/4th metacarpals and into radius, or through 3rd metacarpal if poor bone stock. OR use 2 smaller Steinmann pins. PARTIAL WRIST FUSION: RSL fusion

ETIOLOGY OF MP DEFORMITY -Classic position: ulnar drift and palmar dislocation -Many factors lead to deformity: Less bony stability, wrist deformity, flexor and extensor tendon forces, intrinsic muscle imbalance, forces of gravity and pinch -MP joints are condylar, allowing motion in 2 planes. Therefore they hand less inherent stability than the IP joints -Proliferative synovitis stretches the capsule and ligaments (including collateral ligaments), leading to instability. Extensor tendons shift and dislocate ulnarward. MP JOINT SURGERY -Either preventative (synovectomy), and/or reconstructive (soft tissue reconstruction or arthroplasty) SYNOVECTOMY SOFT TISSUE RECONSTRUCTION -Intrinsic Release -Crossed Intrinsic Transfer Extensor Tendon Relocation MP JOINT ARTHROPLASTY (See ch. 7) THE PIP JOINTS – Progressive PIP synovitis that stretches the extensor mechanism will result in a boutonniere deformity. PIP Synovectomy may be indicated. PIP JOINT SYNOVECTOMY: Slightly curved dorsal incision. Joint exposed between lateral band and central slip. Hypertrophic synovium removed with scapel or rongeur.

FINGER DEFORMITIES: Swan-neck or Boutonniere
SWAN-NECK -Patient evaluation: Categorize PIP motion as no loss, partial loss, to complete loss of flexion. Subdivided complete loss group into either those with and those without preservation of joint space on x-ray. 4 types.




CHAPTER 56 – RHEUMATOID ARTHRITIS IN THE ELBOW (Ferlic) EXTRA-ARTICULAR PROBLEMS OLECRANON BURSAE -Frequently painful, inflamed -Joint infection may present as draining bursa TREATMENT -Culture, then antibiotics. Bursa excision if continued drainage RHEUMATOID NODULES

-Nodules form in areas of pressure, i.e. olecranon. Nodules may be painful and ulcerate. Patients may want them removed, but must be warned that they frequently recur. ANTECUBITAL CYSTS -Occasionally require excision if painful/causing nerve compression WRIST AND SHOULDER -Forearm rotation may be limited by DRUJ as well as proximal radioulnar joint, necessitating radial head resection in addition to distal ulna resection POSTERIOR INTEROSSEOUS NERVE PALSY -If unable to extend fingers, may have several causes: (1) PIN palsy at elbow, (2) subluxation of extensor tendons off MCP‘s, (3) extensor tensor ruptures at wrist -If PIN palsy, should still have tenodesis with wrist flexion, but if wrist or MCP‘s stiff, may be difficult to assess -MRI of elbow may reveal antecubital cyst compressing PIN which may respond to intraarticular steroid injection. Synovectomy/excision of nerve decompression if this fails ULNAR NERVE PALSY -Caused by bony deformity and synovitis -May need decompression, anterior transposition INTRA-ARTICULAR PROBLEMS -Conservative treatment: rest, splinting, analgesics ELBOW SYNOVECTOMY AND RADIAL HEAD RESECTION INDICATIONS -Painful crepitus over radial head with less ulnohumeral involvement. Swelling. Reasonable ROM -Stage II or III on ARA classification

AMERICAN RHEUMATISM ASSOCIATION (ARA) MODIFIED CLASSIFICATION OF X-RAY INVOLVEMENT -Stage I – osteoporosis -Stage II – Slight cartilage or subchondral bone destruction -Stage IIIA – Joint deformity -Stage IIIB – Loss of joint space in 1 view -Stage IV – Loss of joint space in 2 views, ankylosis SURGICAL APPROACH – ELBOW SYNOVECTOMY -Best approach is controversial -APM: lateral approach -Bryan & Morrey: posterior, Inglis: transolecranon -Arthroscopic TECHNIQUE -Posterolateral incision made from posterior border of ulna 4 cm distal to olecranon tip to 4 cm proximal to lateral epicondyle. Keep forearm pronated to protect radial nerve

-Incise fascia between anconeus and extensor tendons, to triceps tendon -Sharply detach extensor tendons from lateral epicondyle and retract anteriorly -Incise capsule, excise radial head, perform synovectomy. Sublux the ulna to remove synovium from the posterior and medial aspects -May need to partially excise coronoid and/or olecranon tips if they limit ROM -If excessive medial pain or ulnar neuropathy, then make medial incision and transpose ulnar nerve anteriorly (see Ch. 44). Reflect muscles off of medial epicondyle, incise capsule, remove synovium. Protect anterior medial collateral ligament and median nerve -Post-op: posterior splint, early ROM RESULTS AND CONTROVERSIAL POINTS -Synovectomy/radial head excision results are good for pain. ROM flex-ex without change, rotation increases 32 degrees -Controversies: +/- radial head excision, synovectomy/radial head excision versus total joint replacement for advanced disease APM: Poor result with advanced disease and adults with JRA. Contraindications to synovectomy/radial head excision: gross joint destruction, instability, secondary severe stiffness resulting from inflammatory fibrosis ELBOW RESECTION INTERPOSITIONAL ARTHROPLASTY (WITHOUT IMPLANT) INDICATION: Case where implant is contraindicated, such as in infection of a failed total elbow replacement TECHNIQUE -Posterior incision from just lateral to midline distally 10 cm, curving medially and extending 10cm proximally. Transpose the ulnar nerve anteriorly. Triceps reflected in ―Y‖ fashion with opening of ―Y‖ at olecranon. Divide radial collateral ligament, dislocate joint -Excise the radial head -Deepen semilunar notch of olecranon and trochlea -Harvest a 5x8 cm piece of fascia lata and suture over semilunar notch -Instability is main problem. Increase stability by: (1) transfer forearm flexor/extensor proximally, (2) insert triceps flap between bone ends, (3) advance distal triceps -Reduce joint, suture collateral ligament, close wound -A & PROM in 3 days RESULTS -Decreased pain, average ROM 100 degrees flex-ex -Failures from further bone resorption, instability ELBOW ARTHRODESIS -Rarely, if ever, indicated -Markedly interferes with upper extremity function

-Single exception may be infected or otherwise failed total elbow arthroplasty where there is not enough bone stock for another procedure or where resection arthroplasty is not acceptable ELBOW IMPLANT ARTHROPLASTY HISTORICAL REVIEW -3 basic designs for total elbow replacements: constrained, semi-constrained, non-constrained -Tried but abandoned: hemiarthroplasty, silicone and rigid hinges ANATOMY -From lateral view, humerus has a 30 degree anterior angulation of articular condyle with respect to long axis of humerus -Axial view of distal humerus demonstrates 5-7 degree internal rotation of articulation in reference to the line connecting the epicondyles -6-8 degree valgus tilt to distal humeral articulation with respect to long axis of humerus TECHNIQUE OF SEMICONSTRAINED (COONRAD-MORREY) ARTHROPLASTY (APM) -Either lateral Kocher approach or posteromedial Mayo approach (APM) may be used LATERAL APPROACH -Preoperatively template components -Patient lateral decubitus -Sterile arm tourniquet -Triceps dissected off olecranon with thin layer of bone and reflected medially -Ulnar nerve decompressed and gently retracted -All structures released from lateral epicondyle in a manner so they may be reattached -Open joint on lateral side, hinging on intact medial ligaments -Perform synovectomy and debridement -Excise radial head proximal to annular ligament -Tips of olecranon and coracoid may need excision -Identify humeral canal with bur or awl; then enlarge with reamer, rasp -Remove trochlea with cutting block -Identify ulnar canal with pin/awl, then prepare with reamers/rasps. (shaft is angled a few degrees lateral to the articulation) -Bone graft from resected trochlea is shaped to fit beneath the anterior flange -Trial components inserted; check ROM, stability, toggle. Do not attempt to attain full extension unless it existed pre-op -Bone plugs inserted 1 cm beyond stems -Canals cleaned, dried -Cement both components, remove excess cement; do not allow hot cement to injure ulnar nerve -Deflate tourniquet, attain hemostasis, place suction drain -Capsule, ligaments, triceps repaired (either to fascia or through drill holes with 5 ethibond) Ligamentous stability not necessary since prosthesis provides it -Transpose ulnar nerve anteriorly -ROM on post-op day 3

COMPLICATIONS -Elbow has highest complication rate of all TJA -Includes infection, neuropathy, skin slough, dislocation CONCOMITANT SHOULDER JOINT REPLACEMENT -Replace most symptomatic joint 1st; if equal, then shoulder 1st since fewer complications -Can do both SALVAGE OF FAILED TEA -Uncontrolled infection: resection (interpositional) arthroplasty (see above) -Eradicated infection: Revision TEA -Aseptic failure: revision TEA; if lacking bone stock, consider bone graft (either 2 or 1 stage) CHAPTER 57 – SKIN GRAFTS (Earl Browne, Jr.) FTSG = full-thickness skin graft. STSG = split-thickness skin graft. INTRODUCTION- Skin is largest organ in body. Skin is composed of dermis and epidermis (epidermis is 5% of thickness). Hand skin divided into dorsal and volar surfaces. Dorsal: thinner, more elastic, loose. Volar: thicker and tougher. SUBSTITUTION OF SKIN GRAFTS – Deeper grafts are better quality, but more difficult donor healing. RESPONSE TO INJURY – Loss of full-thickness skin initiate wound contraction by fibroblasts differentiated into myofibroblasts. Immediate grafting, splinting with compressive dressing for 7 days significantly inhibits wound contraction. Also, the thicker the graft, the less contraction. Wounds mature more rapidly with FTSG vs STSG. FTSG better for palmar wounds (more range of motion) EFFECT OF INFECTION ON WOUND HEALING – Normal is 1,000 organisms of bacteria per gram of skin. If greater than 100,000, then higher probability of infection. VASCULARITY OF THE WOUND – Hematoma will kill a graft. New vascularity from ingrowth of capillary buds into skin graft from wound bed and edges. Grafts will not take on denuded bone or tendon; need flap. TIMING OF GRAFTING – Graft as soon as wound is clean. Immediate debridement and grafting often possible; no more than 2-3 days should pass. BACTERIAL CONTENT DETERMINATION – Take wound biopsy of 1 gram with punch biopsy. Colony-count culture or crush tissue and examine microscopically. Greater than 1 organism per high-power field roughly corresponds to 100,000 organisms. TEMPORARY STORAGE OF SKIN GRAFTS – Few options: 1) Store on donor site, 2) Place in McCoy‘s 5-A medium (good for 2 weeks), 3) Saline soaked sponge in refrigerator (good for few days).

TYPES OF GRAFTS – Full-thickness, Split-thickness, Cultured autogenous epithelial cells, Allogenic. Advantages of FTSG: better protection, hold up better, better sensibility, more epidermal appendages, contract less than STSG. Disadvantages of FTSG: Do not take as readily as STSG, needs better bed, more prone to infection. Palmar skin generally requires FTSG, and dorsal skin STSG. Cultured and allogenic experimental. SKIN THICKNESS – vary depending on location and age SPLIT-THICKNESS GRAFTING – CHOICE OF DONOR SITES: Epidermis regenerates, but dermis does not. Thicker portions of body (posterolateral aspects of trunk and thighs) afford best chanced of good healing when thick graft needed. Most wounds best covered with grafts 0.015 inch thick. Graft should not be taken from areas that patient sits or lies on, or intertriginous area. GUIDELINES FOR STSG THICKNESS AND DONOR SITES: INFANTS – Never over 0.008 inch PREPUBERTAL CHILDREN – If >0.010 inch necessary, remove form lower abdomen or buttocks ADULT MALES – 0.015 inch from thighs, 0.018 inch from abdomen or buttocks ADULT FEMALES – Try never to use inner thich; if > 0.015 inch, use lower abdomen ELDERLY ADULTS – Treat like children‘s skin FREEHAND GRAFTS TYPES OF DERMATOMES BROWN DERMATOME – First automatic dermatome, available in both electric and air-driven models. PADGETT ELECTRIC DERMATOME ZIMMER AIR DERMATOME – APM: Diposable blade in 4 fixed widths. Thickness adjusted by gauge on side. Simple method to check thickness: use #15 blade and place in gap between dermatome and blade. If entire blade barely fits = approximately 0.015 inch. If only sharp edge fits = 0.010 inch. TECHNIQUE: Remove scrub solution on skin with alcohol. Lightly lubricate skin and dermatome with mineral oil. Apply even pressure and countertraction on skin. DAVOL DERMATOME DRUM DERMATOME – Manual, able to get skin from difficult areas. Uses glue or tape. MESH GRAFTING – Allows blood and exudates to escape; may be better if high risk of infection or hematoma. Good for burns and large, contaminated wounds. Only portion with skin is grafted, rest is being left open and allowed to epithelialize. Tendency for contraction and poor cosmetic result, so APM to not usually use for hand. If use in hand, use long-term compression (Jobst pressure glove). PREPARATION OF MESHED GRAFT – Get STSG (0.012 inch optimal). Spread graft shiny side up on carrier (1.5 to 1 for hand); track grooves on bottom. Feed through mesher. Alternate method: cut carrier in 3 sections to put through mesher 90 degree to usual will make multiple punctuate holes which minimizes contraction.

FULL-THICKNESS GRAFTS – Take from relatively hairless areas. Good donor sites: lower and lateral abdominal area, volar wrist crease, medial forearm. For color match, consider plantar skin of instep. For fingertips (better sensibility, ―fingerprint‖ skin), consider hypothenar region. TECHNIQUE OF OBTAINING FULL-THICKNESS GRAFT – Make template of size needed with glove wrap paper. Skin excised in ovoid shape, transverse incision. Excise skin and subcutaneous tissue, undermine and close donor site with subcuticular suture. Then defat graft. PREPARATION OF RECIPIENT SITE – Debride of all necrotic tissue. FILLING THE DEFECT WITH THE GRAFT – For STSG and FTSG: Suture the edges with running chromic, interrupted nylon, or staples. Cover with non-stick gauze (Scarlet Red or Xeroform), bacitracin, saline-soaked cotton balls, foam from scrub brush, then held with the longer end nylon sutures from the edge. Splint. POSTOPERATIVE CARE: If no drainage, smell, fever, then change dressing after 7-10 days. If concern of infection or hematoma, then remove dressing in 24 hours. Stab with #11 blade and drain if needed. Small areas (millimeters) of graft loss are okay; debride larger areas of loss. After 1st dressing change, consider Unna boot dressing. CARE OF THE DONOR SITE – Dry donor site by covering with sponge saturated in lidocaine with 1:200,000 epinephrine for 10 minutes. Repeat if needed. Or use thrombin 5000 U diluted in 5 ml saline. Then place Scarlet Red Gauze, and Reston foam. Or, Duoderm and occlusive steri-drape for 1 week. Alternatively, use open technique: Dry as in above, then dab and keep dry. OUTPATIENT SURGERY – Use lateral femoral cutaneous nerve block 2 fingertips inferior and medial to ASIS with 10 ml Marcaine with epinephrine. CHAPTER 58 – SKIN FLAPS

TYPES OF FLAPS: RANDOM-PATTERN FLAPS = flap where blood supply is not a single arteriovenous pedicle but from many minute vessels of the subdermal or subcutaneous plexus. Raise 3 of 4 sides; unincised side is pedicle or base, opposite side is free margin. -General 1:1 rule: flap length should not exceed pedicle width -―Delay‖ technique (to enhance blood supply): raise flap, then loosely suture back to its bed; transfer 10 days later AXIAL-PATTERN FLAP = flap receives its blood supply from a single, constant vessel. The skin supplied by the vessel is called its vascular territory. -Watershed = where vascular territories of 2 axial pedicleS meet; choke vessels = small arteries that cross it -FLAP SIZE = its vascular territory plus 1:1 extension.

-The vessel may be (1) cutaneous, (2) fasciocutaneous, (3) musculocutaneous -ADVANTAGE OF AXIAL-PATTERN FLAPS OVER RANDOM-PATTERN FLAPS: (1) superior blood supply, (2) less infection, (3) larger flaps, (4) pedicle can be extremely narrow (island or kite flap) permitting more movement, (5) can be converted to free flap 3 CATEGORIES OF FLAPS -Local flap = flap from skin adjacent to the primary defect -Regional flap = flap from elsewhere on same limb -Distant flap = flap from other part of body DEFINITIONS -Primary defect = recipient site = wound to which flap is applied -Secondary defect = wound from which flap is taken -Donor site = region where skin graft is taken RAISING THE FLAP -Use tension / traction -Do not create ―caves‖ -Although it has been shown that metal clips are not secure and that bipolar coagulation may harm the pedicle, both are routinely used -Insulate the pedicle by holding the branch with smooth forceps between the pedicle & coagulation point LOCAL FLAPS -Most desirable way to cover a defect since identical / similar skin quality -However, availability is limited -Test availability by pinching the skin with the hand in various positions = lines of maximum extensibility -3 types of local flaps: (1) transposition, (2) rotation, (3) advancement TRANSPOSITION (LOCAL) FLAPS -2 BASIC TYPES OF RANDOM-PATTERN TRANSPOSITION FLAPS: (1) Transposition leaving a secondary defect requiring skin cover, (2) transposition with direct closure of secondary defect -TYPE I - Transposition leaving a secondary defect requiring skin cover: Equilateral triangle excision of primary defect, extend one line (in direction of the future secondary defect; longer line will make wider flap and less tension), make 2nd cut parallel to triangular line of defect (can extend this to shift the pivot point = ―extension cut‖). Can also make a ―back-cut‖ towards the primary defect. ―Extension and back-cuts‖ are useful tools, but also decrease blood supply. The flap is then raised and shifted laterally relative to the pedicle to cover the defect. -TYPE II - Transposition with direct closure of secondary defect: rhomboid flaps, either Limberg or Dufourmentel. LIMBERG: rhomboid excision of primary defect with all dimensions equal, including the transverse diagonal. Make an incision equal in length (to the sides) off one of the points (=the

promontory), then another parallel to a side. The end is the pivot point which is shifted to the promontory to close the defect. DUFOURMENTEL: rhomboid excision of primary defect with the transverse diagonal any length. 2 sides are extended to the length of the transverse diagonal and another cut is made bisecting these extensions with the length of the sides. The continuing cut is made parallel to the longitudinal diagonal. The pivot is transposed to the promontory VARIANTS OF TYPE I -Gibraiel, Smith ―sliding‖, Gillies ―cocked hat‖ VARIANTS OF TYPE II Z-PLASTY STANDARD 60 DEGREE Z-PLASTY: most common type: limbs are equal length and angles 60 degrees; can lengthen 75%. May perform multiple z-plasties in succession. Use ruler and protractor 4-FLAP Z-PLASTY -Application (i.e. 1st web contracture) -Can achieve 260% lengthening -Limbs of equal length. Cut 120 degrees z-plasty, then bisect the 120 degrees x 2 to get 4 60 degree flaps OTHER TYPES: 2 & 3 flap rhomboid, double z rhomboid, interdigital butterfly flap FLAPS WITH BOTH TYPE I & II FEATURES -Some movement of pivot point occurs, but there is insufficient skin to allow complete closure -Examples: flap from dorsum of thumb or index to create web space in adduction contracture of 1st web space (looks like asymmetric z-plasty with 1 large flap) AXIAL PATTERN -Dorsolateral flaps: pedicle = dorsal digital branches of the digital artery -Flap from dorsal proximal phalanx (esp. index and middle): pedicle = branches of 1st and 2nd dorsal metacarpal arteries AXIAL FLAG FLAP (usually index or middle finger) -Flap is skin over proximal phalanx from mid-lateral line to mid-lateral line, from proximal crease to PIP to level of free margin of web. Raise in plane beneath SQ vascular stratum; leave loose paratenon on extensor hood. Pedicle = web space of donor finger. Flap may cover dorsal or volar aspects of proximal phalanx, dorsal MP joints DORSAL METACARPAL ARTERY FLAPS (FDMA & SDMA) -Flap is from dorsum of proximal phalanx; pedicle has metacarpal artery, veins, radial nerve branches; can be transposed to thumb, 1st web space and ulnar hand REVERSED DORSAL METACARPAL FLAP – As above but skin flap from dorsal hand; axial vessel is communicative between dorsal and palmar metacarpal artery

DIGITAL ARTERY ISLAND FLAPS -Based on a digital artery, used to repair fingertip injuries. Best in middle and ring fingers, where digital vessels are co-dominant; not so in index and little. Flap from lateral finger proximal to DIP. Pedicle carefully dissected, flap rotated to cover fingertip. Donor site covered with small STSG (usually from medial upper arm) ROTATION FLAPS -All are random pattern flaps -Start by triangulating the primary defect, then incise a gentle curve form one of the bases toward the available skin. Make the flap as large a possible (―Think of a flap and then double it‖) -Make a back cut and open it 180 degrees and rotate the flap to cover the defect. Or make a Burow‘s triangle = a triangle of normal skin (on the end of the gentle curve and facing the other direction) which is excised: 2 rotation flaps are then moved in equal and opposite directions. OR cover the donor site with a skin graft. ADVANCEMENT FLAPS -Leading edge of the flap is drawn away from its vascular base to cover the primary defect MOBERG FLAP -For thumb tip amputations at IP level or distal: 2 parallel incisions made just dorsal to the 2 neurovascular bundles, which are carefully preserved. Elevate from flexor tendon sheath. Base at MP flexion crease. If difficulty advancing, 4 options: (1) 2 Burow‘s triangles (see above) at either sides of the flap base, (2) skin at the base can be incised to create an island; FTSG the secondary defect, (3) flex IP, (4) lateral incisions extended into the palm V-Y ADVANCEMENT -Commonly used to repair fingertip amputations -INDICATIONS: Exposed bone, >1/2 nail bed left and supported by bone, tip loss is greater dorsally or equal -May be single midline or double lateral (Kutler) depending where more skin lies -If no bone exposed, then cover with skin graft -If < ½ nail bed left and/or nail bed not supported by bone, then consider ablation of the nail bed and amputation revision 3 SURGICAL POINTERS: (1) More problems arise from inadequate mobilization than excessive. The flap should advance easily into position, (2) Only nerves and vessels need to be kept intact, (3) Nerves and vessels are slender and elastic, and will not resist flap movement. Therefore, tissue that resists may be divided -Apex of the ―v‖ is the distal digital crease -The base is as wide as the nail bed -Raise the flap; do not dissect out individual arteries, veins, nerves individually (will damage). Merely raise on a pedicle of SQ tissue, relying on random vessels therein. REGIONAL FLAPS -Raised from another part of the hand

-both random and axial RANDOM-PATTERN REGIONAL FLAPS (=cross-finger and thenar flaps) -Both for fingertip defects with more palmar than dorsal loss and exposed bone -Thenar flap only for fingertips; cross-finger also for dorsal and palmar loss of all digits -Thenar flap more usually for young women: joints more supple; secondary defect more cosmetic CROSS-FINGER FLAP -For loss of palmar digital tissue, flap is made from dorsal skin over the middle phalanx from mid-lateral line to mid-lateral line, PIP to DIP. -Middle finger to index; otherwise donor finger radial to injured one. -Incised flap margins, coagulate longitudinal veins to reach plane superficial to extensor tendon. May need to extend proximal or distal transverse cut to unlink pedicle -FTSG to cover secondary defect (from inner forearm or arm, wrist, inguinal region 1 cm lateral to femoral pulse) -1st suture 1 edge of the FTSG to the primary defect adjacent to the donor finger -Suture in ―both‖ flaps REVERSE CROSS-FINGER FLAP INNERVATED CROSS-FINGER FLAP = performing cross-finger flap, but also rejoining digital nerves. Not needed since standard cross-finger flap has excellent sensory results (Kleinert, J. Trauma, 1974: 70% with <8mm 2 point) CROSS-THUMB FLAP – Indication: primary defect is radial aspect of index or pulp (if middle finger injured or absent). Flap is raised from the dorsal aspect of the proximal phalanx with a proximal pedicle. FTSG to secondary defect

THENAR FLAP -Injured finger flexed to meet thenar eminence near MP crease; flap hinge is radial. Flap should be 50% longer and wider than defect (since lost pulp is semicircular). Flap is raised with as much SQ tissue as possible. Risk: possible damage to digital nerve of thumb. FTSG secondary defect. Do not suture flap to nail bed, but leave long and trim when flap divided. -Some surgeons concerned re: PIP contracture, but PIP flexion similar to standard cross-finger flap. (Melone JHS 1982: 150 cases, 4% PIP contracture) DIVISION OF RANDOM REGIONAL FLAPS -Standard practice is to divide at 2 weeks, under local anesthesia -Immediate mobilization NEUROVASCULAR ISLAND FLAP -Major indication: damage to the thumb with scarred tender pulp, anesthesia, or relative ischemia -Flap may be from any digit, preferably one that in other respects is unsatisfactory (i.e. one being considered for ray amputation) If all else equal, APM is ulnar aspect of middle finger.

-Before surgery, flow must be checked with Doppler: flow must exist to both digital arteries of the donor finger AND to the contralateral vessels of the adjacent digit (since the other vessel is divided when raising the pedicle) OPERATIVE TECHNIQUE -Outline the pattern of the primary defect; make a tunnel from it to the palm -Choice of joining the ulnar digital nerve to the flap or transecting it far proximally -Apply the pattern to the donor digit; the incision goes from the digit all the way proximally into the palm (zigzag) to the distal margin of the transverse carpal ligament -Initial dissection is in the palm to ensure no abnormal anatomy that would preclude this technique. -Through the tunnel, pass a 1-inch Penrose drain, pass a hemostat from thumb to palm, place a stay suture of 4-0 nylon on the top of the flap. -Raise the flap, including all branches of the nerve and artery. Raise it right off the sheath and bone -Veins are not the main drainage, but small, irregular ones in the SQ fat; therefore the pedicle must be raised as a monobloc of fatty tissue containing all unidentifiable elements. -Ligate the arterial branch of the common digital artery to the adjacent finger -Pass the flap beneath the digital nerve to the adjacent finger and through the tunnel via the Penrose/stay suture/hemostat -Loosely secure the flap in the primary defect and fully abduct / extend the thumb and assure no tension / kinking of the pedicle. If okay, then suture in the pedicle and FTSG the secondary defect FILLET FLAP -Made for well-vascularized digits that are otherwise worthless because of extensive injury to skeleton, nerves, tendons -Fillet = remove skeleton and tendon; flap remains TECHNIQUE FILLET FLAP -Determine vascular status with Doppler -Plan longitudinal incision based on vascular status and how the flap should open and cover (flap is roughly a square) -Consider if finger transposition will be done; fillet can be modified to neurovascular island flap -Longitudinal incision down to skeleton; at the distal end, a circumferential incision made 5 mm proximal to nail -Proximally, save the venous arcade that corresponds to the hinge -With skin hooks/traction, peel soft tissues off of tendon and bone FASCIOCUTANEOUS FLAPS REVERSED RADIAL ARTERY FOREARM FLAP -Not widely used because: (1) depends on good ulnar artery flow, (2) unsightly secondary defect, (3) other free flaps available -Preop assessment of vascular status: Allen test, Doppler – assure patent ulnar and radial arteries and arch

-Using Doppler, mark course of radial artery and veins on skin. Defect pattern marked on volarradial forearm, pedicle swing point at the radial styloid. -Raise the pedicle (skin and fascia – suture together at various points) dissecting in the loose areolar tissue beneath the deep fascia. -Preserve the cephalic vein -Zigzag incision distally over the radial artery -Ligate radial artery proximally and tunnel flap to the primary defect and inset -Tourniquet released and quality of hand perfusion evaluated. If poor perfusion, perform vein graft to the radial artery at the pivot point near the snuffbox (end-to-side) -Secondary defect closed with STSG ULNAR ARTERY FOREARM FLAP -Can be based proximally to cover defects around elbow, or distally for hand cover -Donor site can often be closed primarily -Particularly useful in dorsal hand chemotherapy burns -Technique similar to radial artery forearm flap -Pedicle dissection close to ulnar nerve; most cases with ulnar nerve dysesthesia post-op that usually resolve in a few months REVERSED POSTERIOR INTEROSSEOUS ARTERY (PIA) FLAP -May be proximally based for elbow defects, or distally based for hand defects ANATOMY -PIA arises from common interosseous artery, passes dorsally through the interosseous membrane 6 cm distal to lateral epicondyle. Anastomoses with AIA 2cm proximal to ulnar styloid, passes to dorsum of carpus, anastomoses with radial artery branches. Numerous septocutaneous perforations throughout its course. TECHNIQUE -Draw a line from lateral epicondyle to DRUJ. 2cm proximal to ulnar styloid is pivot point. Measure distance from defect to pivot and map out flap -Raise the flap: incise the radial and distal margins and raise over the EDM radially, identifying the PIA. Similar ulnar dissection made into ECU fascia. Motor branches to ECU may need to be divided and repaired to raise the flap -Clamp PIA proximally to assure good flow, then ligate and move flap to primary defect MUSCULOCUTANEOUS FLAPS LATISSIMUS DORSI FLAP (See Ch. 35) -Can be used as free or pedicle flap -Pedicle can cover shoulder, arm, forearm -Flow standard techniques: pivot point measurement, SQ tunnel, etc. -Close secondary defect; may need rhomboid transposition DISTANT FLAPS=flaps from body parts outside of the upper extremity -Both random and axial pattern flaps -All distant flaps require a period of

attachment between the operated limb and donor part; so they all require at least 2 stages: attachment and division -Random-pattern distant flaps now largely superseded by axial-pattern distant flaps and it, in turn, by free flaps -Still, indications for each exist: --Random-pattern: small defects or ones requiring thin skin where local or regional flaps unavailable (i.e. palmar skin loss, circumferential thumb loss, dorsum thumb loss) --Axial-pattern: Free flap is method of choice; but axial-pattern distant flap may be used if microsurgical expertise or equipment is not available. Free flaps eliminate need for multiple procedures and deliver permanent, vigorous blood supply to the injured part. Another indication for axial-pattern distant flap: pre-pollicization or toe transfer to gain skin/soft tissue at base of digit RANDOM-PATTERN DISTANT FLAPS -Donor sites: inguinal, torso -Follow 1:1 rule -Usually close secondary defect. 3 methods: (1) Simple closure and excise dog-ear, (2) Place 2 Burow‘s triangles at each end of the flap, (3) make one side longer, raise the flap, and place Burow‘s triangle on opposite side -Raise secondary flap at primary defect to suture into free margin of donor site. Accomplishes 2 objectives: (1) close all wounds, (2) secure flap -Strap extremity to donor region (and also consider brachial block) before awakening patient -Consider tissue expansion AXIAL-PATTERN DISTANT FLAPS GROIN FLAP – see Ch. 35 -Cut pattern, test how flap will fit extremity -Fasciocutaneous flap; may divide deep fascia at the lateral border of sartorius from inferior to superior -ROM to all joints -Optimal time for division varies. May divide in 3 weeks if all 3 criteria met: (1) wounds healed, (2) wound long, (3) surrounding skin is supple and unscarred. If not, then; (1) wait, (2) place rubber tourniquet around the pedicle and see if flap flow is good, possibly with needle, (3) if flap divided but flow poor, then do not inset, but wrap and return in 1 week, (4) delay procedure: divide ½ pedicle, then rest in 1 week APM FOR SPECIFIC SITUATIONS Table 58-2, p. 1839 CHEMOTHERAPEUTIC EXTRAVASATION SKIN LOSS -Most common: adriamycin -RX: wide excision of damaged tissue; observation before applying cover: ulnar forearm flap. Free flap if not available

POST-OP CARE -Have patient take early charge of flap; know acceptable positions -ROM to joints; patient mobilized -Pad to air skin -Regular H2O2 cleansing; thin smear antibiotic ointment -Observing and salvaging the flap: see Ch. 33; specifically eliminate kinks in pedicle (accordionlike appearance pedicles do best if they lie on a convex surface and are gently stretched) CHAPTER 59 – ACUTE FLEXOR TENDON INJURIES (Strickland) BASIC SCIENCE OF FLEXOR TENDONS -Tendons composed of Type I collagen (70%, dry weight), elastin, mucopolysaccharides -Surface of individual bundles of collagen covered by endotenon -Epitenon – covers surface of tendon -Flexor tendon enclosed in sheath lined by visceral and parietal synovial layers between which is synovial fluid ANATOMY -FDS on palmar side of FDP. Within proximal sheath, FDS divides into 2 slips that wrap around FDP and rejoin dorsally by fibers called Camper‘s Chiasma and terminate as 2 slips that insert in the proximal ½ of middle phalanx -FDP pass through FDS decussations to insert into proximal ½ distal phalanx. -A2 & A4 arise from periosteum proximal ½ proximal phalanx and mid middle phalanx, respectively -A1, A3, A5 arise form volar plates of MP, PIP, DIP, respectively -C1 between A2 & A3, C2 between A3 & A4, C3 between A4 & A5 -Palmar aponeurosis pulley = palmar fascia; important when sheath pulleys lost -Vincula – filmy mesenteries that attach flexor tendons to sheath -FDP is primary flexor. FDS and intrinsics for power grip (approx. 200 N) FLEXOR TENDON NUTRITION -Nutrition from vascular perfusion and synovial fluid diffusion -Vascular perfusion from : (1) digital arteries by way of vincula, (2) longitudinal intratendinous vessels, (3) vessels that enter tendons at their osseous insertions -Vinculum Brevis Superficialis (VBS) & Profundus (VBP) are shorter and insert near the insertion of the FDS & P respectively -Vinculum Longum Superficialis (VLS) arises from the digital sheath floor of the proximal phalanx -Vinculum Longum Profundus (VLP) arises from the superficialis at PIP level -Vascular supply mainly dorsal BIOMECHANICAL PROPERTIES OF FLEXOR TENDONS -A2 & A4 pulley most biomechanically important; loss of these may diminish motion and power

FLEXOR TENDON HEALING -3 phases: (1) Inflammatory, 3-5 days after repair. Strength is almost all suture. (2) Fibroblastic / collagen-producing, 3-6 weeks. Strength rapidly increases. (3) Remodeling-maturation phase. -Most effective method of returning strength and excursion is strong gap-resistant suture followed by frequent application of controlled motion stress -Experimental enhancing methods: growth factors, chemotaxis and differentiating factors, U/S, electric current, pulsed electromagnetic fields TENSILE FORCES ON NORMAL AND REPAIRED FLEXOR TENDONS Passive Motion: 500 g (normal) / 750 g (repaired) Light Grip: 1500 g / 2250 g Strong Grip: 5000 g / 7500 g Tip Pinch-index FDP: 9000 g / 13,500 g -Tensile forces in tendon increased 50% after repair (25% for edema, 25% for increased friction under sheath) -Force 2-7 x‘s less in FDS than FDP FLEXOR TENDON ADHESION FORMATION AND CONTROL -Factors that contribute to adhesion formation: trauma from injury and surgery, tendon ischemia, digital immobilization, repair site gapping, tendon sheath excision -Many oral and topical agents studied to alter adhesion formation: steroid, antihistamines, beta-aminoproprionitrile, cishydroxyproline, hyaluronan, NSAIDs -Mechanical blocks proposed: silicone, polyethylene tubes, sheath flaps. FLEXOR TENDON REPAIR – EXAMINATION AND DIAGNOSIS OF FLEXOR TENDON INJURIES -Examine resting posture. Laceration on volar finger will injure FDP before FDS. Examine FDP and S for each finger separately. Careful sensory exam to identify digital nerve injury. If both digital nerves are injured, both arteries probably injured also – repair arteries with microsurgical technique ZONES OF FLEXOR TENDON INJURY Zone I – Distal to FDS insertion Zone II – From Zone I to beginning of flexor tendon sheath at level of distal palmar creased. Once called ―no man‘s land‖ because of poor results of repair in this region Zone III – From Zone II to distal edge of transverse carpal ligament Zone IV – Carpal tunnel Zone V – Proximal to carpal tunnel CONSIDERATIONS FOR FLEXOR TENDON REPAIR

-Recovery may be long and tedious, problematic and necessitate multiple surgeries (patient must be counseled) -Repair NOT a surgical emergency; loosely close wound in ER and do in controlled setting in OR later -Repair both FDS & P -If contaminated wound, delay repair until clean INCISIONS FOR SURGICAL EXPOSURE -Zigzag or midaxial incision; do not compromise skin flaps or create contracture -Need to extend to find tendon ends FLEXOR TENDON RETRIEVAL -Tendons often retract; retrieval may be difficult -2 most reliable retrieval methods: (1) If tendon is visible, use skin hook to grasp and pull distally. Hold with transverse 25-gauge needle. (2) If tendon not visible, Sourmelis / McGrouther method: pass a small catheter (infant gastrostomy feeding tube is ideal) from distal into palm. Through mid-palmar incision, suture both tendons to catheter several cm proximal to A1. Pull catheter distally, delivering tendons and hold with needle. -Important to recreated proper FDS/P anatomic relationship

TECHNIQUES OF FLEXOR TENDON REPAIR CORE SUTURES General conclusions: (1) Strength of repair approximately proportional to number of suture strands that cross repair site, (2) Locking loops contribute modestly to strength but may collapse and lead to gapping at moderate loads, (3) Repairs usually rupture at suture knots, (4) Each progressively larger suture caliber increases repair strength significantly, (5) Synthetic 3-0 or 4-0 braided sutures probably best (although polyfilament ensheathed by caprolactan (Supramid) was found to be strongest by 1 investigator, (6) The fewer knots the better, and it is better to have knot outside the tendon repair site, (7) Significant strength and biomechanical advantages to dorsal vs. palmar core sutures, (8) Best to have equal tension across all suture strands, (9) 4 strand is 2x and 6 strand is 3x as strong as 2 strand repair PERIPHERAL EPITENDINOUS SUTURES -Will increase strength 10-50% and significantly reduce gapping -Strongest techniques: running lock, cross-stitch (Silfverskiold), horizontal mattress, epitenon/intrafiber SHEATH REPAIR (with 6-0 nylon) -Conflicting studies regarding benefit -Experimental sheath substitutes: tendon, fascia, retinaculum, peritoneum, sheath, synovium, vein, nylon, cellophane, polytetrafluoroethylene PARTIAL TENDON LACERATIONS

-If <60%, no repair needed TENDON REPAIR APM: 4 strand core suture (Kessler-Tajima & Horizontal Mattress) with running-lock peripheral epitendinous suture. Kessler-Tajima: Needle enters tendon end, makes loop/lock, cross tendon transversely, make loop/lock and exit end of tendon. Do this to both ends; should have 4 free ends. Horizontal mattress: Needle enters tendon end, exits (closer to end than Kessler-Tajima), re-enters and then exits out tendon end. Enter other end and repeat; should have 2 free ends. -Order of repair: Place Kessler-Tajima (but do not tie). Place back wall of running-lock peripheral epitendinous suture. Place horizontal mattress and tie all core sutures. Finish front wall of peripheral suture. GENERAL CONSIDERATIONS OF TENDON REPAIR -2x to 4x loupes needed -Atraumatic technique needed: Avoid pinching / crushing tissue. Use delicate instruments and technique. -Exposure: Bruner ―zigzag‖ or midaxial extension of existing wounds. Protect / repair nerves / arteries. -Open sheaths at cruciate portions. Use mid-axial / ―L‖ incisions. -Preserve annular portions -Other core techniques: Robertson, Lee, Sandow, Lim/Tsai SPECIFIC INJURIES (by Zones) ZONE I – Proximal tendon end usually retracts to PIP level or proximal. May have to open C3 to find distal end and C1 or 2 for proximal end. Perform end-to-end repair. If distal stump too short, then elevate osteoperiosteal flap at base of distal phalanx and drill an oblique hole to penetrate out mid fingernail. Double-armed straight needle 3-0 nylon used to hold tendon tied over cotton pad-button x 6 weeks. (Alternative: suture bone anchor) Supplement with sutures to adjacent periosteum or sheath. ZONE II – Repair both FDP & S. Must re-establish anatomic relationship. THUMB – Similar to Zone I & II. FPL may retract to carpal tunnel; may be simpler to locate tendon beneath FCR at wrist and use Sourmelis / McGrouther method. ZONE III – Use conventional palmar incision and standard repair techniques ZONE IV – Often with median nerve injury. Repair tendons with above techniques. ZONE V – If multiple tendons, may be practical to eliminate peripheral epitendinous suture. POST-OPERATIVE MANAGEMENT -No definite agreement on best method

-3 main techniques: (1) Active Extension – Rubber Band Flexion Method, (2) Controlled Passive Motion Method, (3) Controlled Active Motion Method -Common features to all: (1) Compensates for swollen finger, (2) Keeps wrist (20 degrees) flexed and MP flexed at rest, (3) Keeps PIP & DIP extended at rest, (4) Permits passive digital flexion with wrist flexed, (5) Keeps wrist extended (45 degrees) and MP 90 degrees if light active motion is permitted, (6) Uses frequent application of motion stress, (7) Aggressive use of hand not allowed until after 8 weeks post-op ACTIVE EXTENSION – RUBBER BAND FLEXION METHOD -Dorsal block splint (orthoplast), rubber band from wrist, under palmar bar, then to fingernail (hook glued) CONTROLLED PASSIVE MOTION METHOD -Splint as above. Passive MP, PIP, DIP flexion CONTROLLED ACTIVE MOTION METHOD -Splint with wrist hinge (MP at 60-90 degrees, IP‘s extended). With wrist flexed 20 degrees, passively flex fingers (tip-to-palm). Extend wrist to 30-45 degrees and actively hold fingers flexed for 5 seconds. FLEXED TENDON INJURIES IN CHILDREN -Use smaller core sutures: 4-0 or 5-0 -Early motion protocols difficult secondary to compliance -May need to immobilize post-op (do not exceed 4 weeks, however) COMPLICATIONS RUPTURE – Needs prompt re-exploration and repair. MRI or U/S if not sure of dx. JOINT CONTRACTURE – Most frequent complication (PIP &/or DIP). RX: Modify rehabilitation: greater extension and consider dynamic splints TENDON ADHERENCE – Several months rehabilitation. Consideration tenolysis (see Ch. 60) if wounds at ―equilibrium‖: soft pliable skin & tissue SALVAGE PROCEDURES -May need staged reconstruction using passive or active tendon implants. Allografts & synthetic prostheses experimental -Pulley reconstruction (autogenous & synthetic) proposed -Consider arthrodesis or amputation if finger is painful and non-functional FLEXOR TENDON AVULSIONS AND RUPTURES -Spontaneous rupture in finger, palm, wrist, forearm -Causes: RA, chronic tenosynovitis, partial laceration, attrition over bony prominence, TFCC calcification -MRI may help dx -RX: repair (as above)

FDP AVULSION -Also called ―Jersey Finger‖ -Most often in young, male athlete, ring finger (75%) -Often missed initially, able to flex PIP & MP 3 MAIN TYPES TYPE I – FDP retracts into palm. Avulsion with no or small bony fragment. Must be repaired within 7-10 days. Retrieve by Sourmelis / McGrouther method by opening C1 region distally and mid-lateral or zigzag incision proximally. Reattach FPL (see Zone I discussion above) If unable to directly repair, consider (1) Leave alone, (2) Free tendon graft, (3) DIP (arthrodesis) TYPE II – Tendon retracts to PIP. May have small bony fragment. Often possible to repair as late as 6 weeks (since less shortening) Retrieve through C3 and repair as in Type I. TYPE III – Tendon retracts only to A4. Large bony fragment stops further retraction. RX: ORIF / K-wires. In some cases, there may be fx and avulsion. CHAPTER 60 – FLEXOR TENDONS – LATE RECONSTRUCTION (Schneider) ANATOMY -Double-layered synovial sheath in fingers. Visceral layer closely applied to tendons and outer parietal layer, joined at each end, with a space in between, filled with synovial fluid -Mesotenon – connects the 2 synovial layers and conveys blood vessels to the tendon. Mesotenon is condensed into vinculum breve and vinculum longum INDICATIONS – SINGLE STAGE TENDON GRAFTING: (1) Late referral, missed diagnosis, (2) Wound or general conditions do not allow early repair TECHNIQUE – ZONE II -Generally, tendon graft from palm to distal phalanx. Need to have full passive motion pre-op. Tourniquet, Bruner incision. Excise injured FDP leaving 1 cm stump distally, up to lumbrical origin in palm. The more resilient tendon, FDS or FDP (usual) is selected for motor. Excise FDS: Pull distally and transect as proximal as possible. Distally, leave 1-2 cm FDS stump. If PIP is loose and hyperextensible, then leave one tail of FDS long and suture it to flexor sheath proximal to PIP to tenodese it at 10-20 degrees flexion -Thread tendon graft (see below for obtaining) under pulleys with suture passer, rubber catheter, etc. (surgeon‘s choice) -DISTAL JUNCTURE (APM) – Through bone tunnel at base of distal phalanx tied over button (3-0 Prolene) (see Ch. 59) Split FDP stump and tie (4-0 ethibond) sutures from graft, FDP stump and periosteum. Other methods: (1) For children, just latter ½ of above (no bony tunnel) (2) Transverse bone tunnel at base of distal phalanx (pass graft through and tie to itself) -PROXIMAL JUNCTURE (APM) = PULVERTAFT WEAVE: Make slit in motor end and weave graft through. Make another slit in a different plane and weave through. The more

weaves, the stronger it is (up to 4 to 5 weaves). Fish mouth the end of the motor end and put graft into the mouth. Fix all weave points and fish mouth with 4-0 ethibonds.

OBTAINING FREE TENDON GRAFTS PALMARIS LONGUS (APM) – Present in 90%. Test for presence pre-op by opposing thumb to little finger and flexing wrist. Good for 1 graft. TECHNIQUE (APM): Transverse incision at wrist, identify tendon and mobilize, transect as distal as possible. Place holding stitch and use tendon stripper. If tendon stripper not available, then make multiple transverse incisions until able to transect proximally at M-T junction. PLANTARIS TENDON – Present in 80% (U/S may help to evaluate pre-op). Can supply 2-3 palm-to-fingertip grafts or 1 long forearm-to-fingertip graft. TECHNIQUE: 5 cm vertical incision just anterior to medial aspect of Achilles tendon. Identify and bluntly dissect tendon, divide distally, tendon stripper (with knee extended) LONG TOE EXTENSORS – of 2, 3, 4th toes. Frequent problem: tendons fuse not allowing 3 long grafts. TECHNIQUE: Generous transverse incision made at dorsum of foot at MP level, isolate tendon and strip to resistance. Make another transverse incision and free. At ankle level, cruciate crural ligament must be opened. Proximal to this, strip up leg. If tendons merged, need more incisions and dissect out tendons. FDS, EIP, EDM – rarely used. TENDON ALLOGRAFTS – not had widespread acceptance TENDON GRAFT LENGTH: ADJUSTING TENSION (APM): Complete distal juncture first. At proximal juncture with Pulvertaft weave technique, place one suture and look at fingers‘ position with wrist neutral. Each finger should fall into semi flexion, slightly less flexed than its ulnar neighbor. QUADRIGA SYNDROME = Too much tension in one FDP causes decrease power and excursion in remaining FDP‘s (because of common origin). -Named by Verdan after Roman 4-horse chariots controlled by 1 driver with 4 reins -Sxm: c/o flexion deformity of injured finger and weakness of grasp in other fingers -PE: Weak, deficient FDP in other fingers -Reasons: (1) FDP advanced too distally in Zone I repair, (2) short tendon graft, (3) distal finger amputation where flexor tendon is sutured to extensor, (4) amputation where FDP adheres to phalanx -RX: Lengthen, tenolyse, or even sever offending tendon POST-OP MANAGEMENT OF TENDON GRAFTS -Similar to direct repair (see Ch. 59)

TENDON GRAFTING (ZONE I) -For chronic Zone I injury, many patients (if FDS fully functional, DIP stable, and no-minimal c/o) need no RX. -Alternatives to tendon grafting: arthrodesis or tenodesis -Offer tendon grafting with caution (patients can be made worse). Better candidates: (1) If FDS not flexing adequately, (2) younger patient who needs active DIP, (3) ulnar fingers more justified (for power grip). -ZONE I TENDON GRAFTING TECHNIQUE – as above. Thinner graft (plantaris) is easier to pass. Pass graft through FDS decussation if possible, go around if not RECONSTRUCTION OF FPL -Direct repair usually possible for 3-4 weeks post-injury. If not, then several options: TENDON GRAFT: Similar to fingers. Volar zigzag approach. 2nd incision volar-radial distal 6cm forearm. Identify FPL at M-T junction and pull-out tendon. Complete distal and proximal tendon graft junctures with wrist neutral, thumb abducted 30 degrees at CMC, IP 30 degrees. Post-op: controlled early motion.

FDS TRANSFER OF RING FINGER TO FPL -Volar zigzag approach to thumb. Distal forearm incision to remove tendon. Transverse incision at base of ring finger, find FDS, tag, and transect 2cm proximal to PIP. Locate this FDS in forearm wound and pull out and redirect through FPL sheath. (may need palmar incision to release interconnections) Distal juncture as previously described. OTHER OPTIONS: (1) IP arthrodesis (at 10-20 degrees) if IP joint damage or hyperextensible and need strong pinch, (2) do nothing, (3) advancement, limited to 1 cm, (4) lengthen z-plasty at M-T junction SECONDARY RECONSTRUCTION OF TENDON INJURIES IN ZONES III, IV, & V: -Need generous exposure: find tendons at normal anatomy -If tendons not retracted, perform end-to-end repair -To repair both FDP & S vs. only FDP is judgement call. If soft tissue scarring severe, just repair FDP. Gliding FDP is better than adherent FDP & S repairs. -3 methods of reconstruction: INTERPOSITION GRAFTKessler-Tajima or Bunnel stitch both ends, place tendon graft tendon graft (injured FDS or PL) threaded in between ends. Graft may be tacked at each juncture with fine nonabsorbable encircling stitch. SUPERFICIALIS TRANSFER Adjacent FDS transected and end-to-end transfer (Bunnel or Kessler-Tajima) deep to neurovascular structures. May need to sacrifice A1. END-TO-SIDE PROFUNDUS juncture

Attach distal end of severed FDP to intact adjacent FDP with Pulvertaft weave (best in Zone V) POST-OP -Controlled early motion FLEXOR TENOLYSIS INDICATIONS – Plateau in ROM for at least 3 months (some advocate 6 months) -Long discussion and consideration with patient; finger can be same or worse (atrophic, cold) after tenolysis. 50% normal ROM may be reasonable to accept -If finger has had multiple insults, consider arthrodesis or amputation -May also need joint contracture release with tenolysis -Prepare patient preop for possible staged tendon reconstruction if other problems (juncture rupture or gap) ANESTHESIA -Best to perform digital block and conscious sedation so patient can actively move finger TECHNIQUE -Ample volar zigzag incision, uncover entire length flexor tendon if needed. Excise all limiting adhesion, defining borders of tendon. Leave filmy, nonlimiting tissue. Preserve pulleys; if not possible, then construct new pulleys (consider staged tendon reconstruction), although this worsens results. AROM frequently. If tourniquet paralysis, then release. May need to re-inflate. Post-op: AROM. ADJUNCTS TO TENOLYSIS STEROIDS – Some advocate local injection (decreases adhesions), author does not use INTERPOSITION MATERIALS – Some advocate, author does not use TWO-STAGE FLEXOR TENDON RECONSTRUCTION – GRAFTING IN LESS THAN OPTIMAL SITUATIONS INDICATIONS FOR TWO-STAGE TENDON RECONSTRUCTION (HUNTER TENDON IMPLANT): (1) previous repair/graft is gapped or ruptured, (2) bed very poor, (3) pulleys inadequate, (4) severe crush, (5) infection, (6) contractures General Idea: Stage I – Silicone rubber tendon implant placed for 3 months creates a sheath, Stage II – Tendon graft placed in this new sheath Patient Selection – Patient must understand complexity. Consider arthrodesis or amputation. If finger with severe neurovascular impairment, poor candidate. SURGICAL TECHNIQUE STAGE I – IMPLANT: General anesthesia. Expose flexor system with volar zigzag approach to lumbrical in palm. Ignore mid-lateral

incision, if previously used. Preserve all potential pulleys. Excise flexor tendons; leave 1 cm FDP stump on distal phalanx. Leave FDS tails distally for possible pulley reconstruction. Proximal FDP transected at lumbrical level; excise lumbrical if scarred. Set aside excised tendon in moist sponge for possible pulley reconstruction. Possible volar plate and accessory collateral ligament release if contractures. -2nd curvilear incision in ulnar distal forearm. Identify involved FDS, draw into wound, and transected at M-T junction. Set aside tendon. -Trial set of Hunter tendon implants (adult male: 4-6mm): Thread trial through pulleys and should be movable with minimal resistance. Need at least A2 & A4, but more pulleys are better. Place actual implant from distal-to-proximal, pass between FDP & S proximally with suture passer. -Distal Juncture (2 methods): (1) Wire suture: Trim distal end of implant, #32 monofilament stainless steel wire figure-8 stitched to Dacron end of implant and this tied to FDP stump, reinforced with 2 4-0 nonabsorbable sutures from stump, implant, periosteum. (2) Screw-plate: Use metal end implant and fix with 2 mm AO screw. -Traction on implant proximal end. If bowstrings, need pulley reconstruction. If tight pulleys/retinaculum, stretch with curved hemostat, or remove. -POST-OP: Splint wrist 30 degrees flexed, safety position; PROM x 3 months. STAGE II –Implant removal and Tendon Graft Insertion -Distal portion finger incision opened to middle phalanx. Locate implant. Open forearm incision and locate implant. Select motor, usually FDP to digits 3-5. For index recon, FDP to index chosen, or FDS. For FPL, FPL or an FDS or FDS to ring transfer chosen. -Obtain tendon graft (PL, etc.) -Suture tendon graft to proximal end of implant and pull through pulleys. Discard implant. -Secure distal juncture (over button – see Ch 59) -Secure proximal juncture: Pulvertaft weave if one motor (see Ch. 59) or interweave if FDP mass 3-5 chosen (multiple stabs in tendons, graft weaved through) POST-OP – Early controlled-motion program

RECONSTRUCTION OF THE PULLEY SYSTEM ANATOMY – A2 & 4 are from bone. A1, 3, 5 arise form volar plate and bone. Approximate widths: A1 (10mm), A2 (20), C1 (4), A3 (3), C2 (3), A4 (12), C3 (1 band), A5 ANATOMY OF THUMB PULLEYS A1 at MP, 9mm, from volar plate and bone. Oblique pulley over proximal phalanx, 11mm. A2 from IP volar plate, 10 mm. -If significant bowstringing, effect is decreased ROM and flexion deformity -Removal of cruciates and A5 result in no obvious loss of ROM -A2 & 4 may not be enough (more pulleys are better), but may not be surgically practical -Suture reparable pulleys -Reconstructed pulley must be strong and vigorously tested intra-op

-Biomechanical studies: encircling technique – strongest (Widstrom JHS ‘89) METHODS OF PULLEY RECONSTRUCTION (use 4-0 nonabsorbable suture): FREE TENDON GRAFT ENCIRCLING (APM for A2 level): -Encircle proximal phalanx 2-3 times deep to extensor mechanism. Need 6-8 cm of tendon graft for 1 circle; pulley should be 10 mm wide. Do not include neurovascular bundle. May also encircle middle phalanx (at A4 level), superficial (encircle) to extensor mechanism. FREE TENDON GRAFT INTERWOVEN INTO RIM OF PULLEY REMNANT – not as strong as above. Attaching to bone through drill holes discouraged (risk of fracture) FDS TAIL – If tail of FDS long enough, leave attached distally and free end suture to contralateral rim of original pulley or periosteum. Others Methods: Extensor retinaculum, volar plate, artificial material POST-OP: Early motion. 2cm orthoplast ring to protect pulley recon x 8 weeks COMPLICATIONS IN 2 STAGE TENDON RECONSTRUCTION SYNOVITIS – response to implant (8%). Present with heat, crepitus, swelling, may get binding of implant. RX: Decrease exercise; may need earlier Stage II. INFECTION – Remove implant, give antibiotics. Consider re-implanting in 3-6 months. FDS FINGER: A SALVAGE PROCEDURE -Misnomer since FDP usually motor, placed into base of middle phalanx, held with pullout suture / button -Uses: (1) If tendon graft ruptures at distal juncture, (2) If DIP inadequate (intraarticular or extensor mechanism damaged) ACTIVE TENDON IMPLANTS -Search for permanent implant ongoing -Active tendon implant attached distally and proximally, but is then replaced by tendon graft or transfer 3-4 months later. Indications similar to passive implant. -Technique similar to passive technique, except proximal juncture fixed with: (1) Fixed Loop Implant: motor tendon end passed through implant loop and then back into itself. Tension checked, then interwoven into itself 3-4 x‘s, (2) Dacron Braid End Implant: interwoven into tendon -Results of active and passive implant techniques similar (APM: passive) FLEXOR TENDON RECONSTRUCTION IN CHILDREN -Direct repair if possible, if not, wait until child > 7 years old for tendon grafts (problem if too young: small size of tendons and inability of children to cooperate in post-op care / rehab)

-Distal juncture not into bone, but into FDP stump. If no stump, then into bone distal to epiphysis. -Plantaris often too thin to use

CHAPTER 61 – ACUTE EXTENSOR TENDON INJURIES (Doyle) General rules: Repair only if >50% extensor tendon injury. Suture: 4-0 & 5-0 non-absorbable synthetic suture -Divided extensor tendons are usually free to retract only on the dorsal wrist -Therefore, many extensor tendon injuries, especially in the fingers, may be treated by splinting alone. ANATOMY: -Finger extension is complex, composed of 2 separate and neurologically independent systems: (1) radial nerve innervated extrinsic extensors, (2) ulnar and median nerve-innervated intrinsic system. -6 dorsal tunnels -4.9 cm wide extensor retinaculum -JUNCTURAE TENDINUM = oblique interconnections that join EDC tendon proximal to MCP level -Extensor tendon held in place over center of MCP by sagittal band and conjoined tendons of intrinsic muscles -Sagittal bands arise from volar plate and intermetacarpal ligaments -The conjoined tendon (from the lumbricals and interosseous muscles) joins the extensor mechanism at proximal phalanx and continues to DIP -At MCP, intrinsics are palmar to axis of rotation; at PIP, they are dorsal -Extensor mechanism at PIP is trifurcation of extensor tendon into central slip and 2 lateral bands -Central slip – attaches to base of middle phalanx -Lateral bands continue to insert on dorsal base of distal phalanx -Transverse retinacular ligaments – maintain extensor mechanism in place over PIP -Central slip and lateral bands are in delicate balance. If central slip is lengthened ( boutonniere deformity ANATOMIC VARIATIONS (ANOMALIES) -20% of population has some variation -EXTENSOR CARPI RADIALIS INTERMEDIUS (ECRI) – origin between ECRL and ECRB – can be used as a transfer for thumb opposition, to motor FPL or EPL -EXTENSOR MEDII PROPRIUS (EMP) – analogous to EIP, but inserts on middle finger -EXTENSOR INDICIS ET MEDII COMMUNIS (EIMC) – anomalous EIP that splits and inserts into index and middle fingers

EXTENSOR DIGITORUM BREVIS MANUS (EDBM) – Fusiform muscle (usually soft mass) between index and middle finger metacarpals with varying relationships to EIP. SXMS: May have pain. PE: Fusiform mass, firms with wrist flexion and finger extension. RX: Excision if significant sxms ZONES OF INJURY FINGERS: I - DIP, II – Middle phalanx, III – PIP, IV – Proximal phalanx, V – MP, VI – Metacarpal, VII – Dorsal retinaculum, VIII – Distal forearm, IX – Mid- and proximal forearm THUMB: I – IP, II – Proximal phalanx, III – MP, IV – Metacarpal, V – CMC / radial styloid RESULTS IN EXTENSOR TENDON INJURIES -Results evaluated by TAM (total active motion), extension lag and flexion loss, grip strength -60% with associated fracture, dislocation, etc.; these have 45% good-excellent results -64% good-excellent with no associated injury -Distal injuries (Zones I-IV) do worse than proximal

DYNAMIC SPLINTING AND EARLY ACTIVE MOTION FOR EXTENSOR TENDON INJURIES APM: Zones I & II: Static immobilization -Zones III – VIII: Dynamic splinting and early active motion (in compliant patient with hand therapist) Static immobilization for children and uncooperative adults. -Dynamic splinting and controlled, early PROM important! -5mm tendon glide safe and effective in limiting adhesions -Dynamic splint with outrigger (wrist extended 35-45 degrees): active flexion (10x/hr) to block, passive extension with outrigger. Sleep with static splint with fingers in extension Started 3-5 days post-op x 5 weeks. Progressive resistive exercises at 6 weeks. SPECIFIC EXTENSOR TENDON INJURIES MALLET FINGER = ZONE I CLASSIFICATION Type I: From closed trauma. With or without avulsion fracture. Most common. Type II: From laceration Type III: From deep abrasion with loss of skin, SQ, tendon Type IVA: Transepiphyseal plate fx in child Type IVB: Hyperflexion with fx articular surface 20-50% Type IVC: Hyperextension with fx articular surface > 50% , with early or late volar subluxation of distal phalanx TREATMENT TYPE I (APM): Volar stack splint or aluminum foam splint across DIP; avoid hyper-extension, wrap with moleskin; may place dorsally and/or volarly—full time x 6 weeks. -Splint no matter how chronic -If PIP hyperextended, splint in 30-45 degrees flexion

-At 6 weeks, begin guarded flexion exercise 10-20x / 2 hours; splint in between and pm x 2 weeks. If extension lag, splint 2 weeks and repeat process. -If uncooperative patient or child: plaster cast: 18 inch strip 3 or 4 inch dry plaster rolled in tube and slipped over finger (no padding). Dip in water, mold: DIP 0 degrees, PIP 30-45 degrees. TYPE II – APM -Repair with running suture of 4-0 or 5-0 synthetic, approximating skin and tendon simultaneously -Splint DIP at 0 degrees. D/C suture at 10-12 days, then splint x 6 weeks, etc. as in Type I. TYPE III – APM -May need skin coverage, late tendon graft or arthrodesis (see Ch. 62) TYPE IV – APM -ORIF if volar subluxation: Expose DIP through dorsal zigzag incision. 0.035-inch K-wire passed longitudinally in to out distally. Reduce joint with DIP at 0 degrees and drive K-wire across DIP. If fracture fragment not opposed, then hold with pull-out suture or wire (4-0) tied over a padded button on finger pad. Splint. D/C splint and K-wire at 6 weeks. MALLET THUMB – APM -Similar as for mallet finger FINGER MIDDLE PHALANX AND THUMB PROXIMAL PHALANX = ZONE II -Usually from laceration -If <50% of tendon, then skin care and AROM at 7-10 days -If >50%, then run suture near tendon edges, followed by Silfverskiold-type cross-stitch (makes ―x‖ repeatedly, looks like laced shoe) proximal and distal to running stitch BOUTONNIERE LESION, PIP JOINT (=ZONE III) -Boutonniere deformity – occurs when central slip is disrupted and lateral bands migrate volarly. Subsequent loss of PIP extension and compensatory hyperextension of DIP. Either closed (acute forceful flexion of PIP) or open (laceration) -Deformity may not appear for 1-3 weeks -Early diagnostic tests: point tender at central slip insertion, loss / weak PIP extension PSEUDOBOUTONNIERE DEFORMITY = PIP joint contracture with associated restricted DIP flexion. Caused by hyperextension injury TREATMENT OF CLOSED ACUTE BOUTONNIERE (ZONE III) INJURIES (APM) -Joint Jack splint (constant), tighten daily. Goal: PIP 0 degrees. A & PROM DIP x weeks until PIP 0 degrees and full flexion DIP. Can use for > 6 months. Slow PIP mobilization after splinting: active PIP extensor, flexion < 30 degrees, increase 20 degrees / week. If PIP extensor lag develops, re-splint.

TREATMENT OF EXTENSOR TENDON LACERATIONS OVER PIP JOINT (ZONE III) (APM) -I & D joint, Abx -Modified Kessler stitch of 4-0 synthetic suture 1 cm from tendon edge, followed by Silfverskiold cross stitch with 5-0 synthetic. Intra-op test: PROM PIP to 30 degrees without gapping. If inadequate distal tendon, then suture through transverse bony tunnel made with 0.035-inch K-wire. Splint PIP at 0 degrees. Ideally, short arc motion protocol with hand therapist post-op. Alternatively (not as good), protocol as in closed injury. If tendon loss, Snow described distally-based flap of central slip to span gap. Aiche described dissecting lateral bands, slitting them longitudinally 2 cm, reapproximating middle segments in midline. THUMB INJURIES (ZONE III, MCP) (APM) -I&D joint, Abx -Standard core type suture to EPL and/or EPB, modified Kessler stitch with 4-0, and cross-stitch with 5-0 -Repair capsule if needed -Dynamic splint post-op PROXIMAL PHALANX (ZONE IV) -Usually partial laceration because of broad tendon over curved bone. Can only fully diagnose (%) by direct inspection . RX: 5-0 cross-stitch if isolated lateral band injury. If larger larger injury modified Kessler 4-0 suture with 5-0 Silfverskiold cross-stitch. Post-op: short arc motion. THUMB INJURIES (ZONE IV, METACARPAL) -Repair EPB / EPL with core-type modified Kessler & cross-stitch. Dynamic splint post-op. FINGER INJURIES (ZONE V, MP JOINT) HUMAN BITE WOUNDS – Usually from punch to mouth; many patients deny mechanism. Staph a. +/- Gram negative most common. X-ray to R/O fx, foreign body. Must extend wound proximally and distally, irrigate / debride, and leave open (never close). Antibiotics. Do not repair tendon immediately. Splint hand (wrist 45 degrees extended, MCP 15 degrees. If tendon laceration > 50%, then repair (see below) when clean (may be several days later), then dynamic splint. LACERATIONS -RX: Core-type 4-0 modified Kessler stitch with 5-0 cross-stitch. Dynamic splint post-op. CLOSED SAGITTAL BAND INJURIES -spontaneous rupture of sagittal band (usually radial) with subsequent subluxation/dislocation of tendon. May have incomplete finger extension and (usually ulnar) deviation of finger. -RX: if acute (<2 weeks), flexion block splint (10-20 degrees) with IPs free for 6 weeks. If >2 weeks, sagittal band recon (see surgical techniques) THUMB INJURIES (ZONE V, CMC joint)

-Possible injuries: EPB, EPL, APL, radial sensory nerve, radial artery. Tendons repaired with modified Kessler and cross-stitch. Post-op: Dynamic splinting. FINGER INJURIES (ZONE VI, METACARPAL) -RX: Core-type modified 4-0 Kessler and 5-0 cross-stitch. Post-op: Dynamic splinting (wrist 45 degrees extended, MP 15 degrees flexed) x 5 weeks. -Better prognosis than distal lesions SECRETAN’S DISORDER (PERITENDINOUS FIBROSIS) -Etiology and RX controversial -HX & SXMS: Usually male worker, blow to dorsal hand with firm swelling, loss of finger ROM, out of work -APM: Factitious disorder: patient not feigning, but causing self-inflicted trauma -DX: Based on H&P. MRI may show soft tissue edema and peritendinous fibrosis -RX(APM): Psychotherapy (Do not confront / accuse), physical therapy; problem may resolve when compensation terminated WRIST INJURIES (ZONE VII) RX: Extend wound and find retracted tendons. Place core-type 4-0 modified Kessler stitch in each end, hemostat stitch, label each with steri-strip. May need limited excision of portions of retinaculum to aid in exposure and avoid impingement of gliding. Some retinaculum should (and usually can) be preserved. Tie suture; test for glide by PROM wrist / fingers. Post-op: as in Zone VI. DISTAL FOREARM INJURIES (ZONE VIII) -May be from laceration or traumatic rupture. If tendinous, use core-type suture. If muscle, tendon transfer or side-to-side suture. PROXIMAL FOREARM INJURES (ZONE IX) -Usually form knife or glass RX: Exploration (for nerve / muscle injury). Repair muscle (look for intramuscular septa and fascia) with multiple figure 8 vicryls (rabbit study showed useful but not full function). If cannot obtain suitable repair and > 2 muscles with > 50% muscle laceration, then consider tendon grafting: PL and / or toe extensor passed through superficial epimysium, muscle belly, deep epimysium proximally and distally and sutured to themselves with Pulvertaft weave. If still suitable repair not possible, consider tendon transfers. -Post-op: Immobilize elbow 90 degrees, wrist 45 degrees extended, MP 15 degrees x 4 weeks; then 2 weeks pm splint. -If questionable nerve injury but cannot find nerve ends, consider NCS/EMG after 3-4 weeks and consider nerve repair/graft versus tendon transfers. CHAPTER 62 – EXTENSOR TENDONS – LATE RECONSTRUCTION (Burton, Melchior)

ANATOMY & FUNCTION -Complex system that flexes 1 joint and extends 3 -Extrinsic Extensor System – Radially innervated, 4 insertions (MP volar plate via sagittal fibers and dorsal base of each phalanx). Extends MP. -Intrinsic Extensor System – 7 interosseous and 4 lumbricals – pass volar to MP and dorsal to IP‘s. Flex MP and extend IP‘s -Thumb has independent extensor for each joint: EPL to IP, EPB to MP, APL to CMC. GENERAL ANATOMIC / FUNCTIONAL CONCEPTS -Finger extension synergistic with wrist flexion -Distal to MP, extensor mechanism is a single fascial – tendon expansion -Extensor tendon complex is a series of overlapping linkages, volar to axis at 1 joint and dorsal at next distal: Intrinsic at MP & PIP; oblique retinacular ligament at PIP & DIP. -Tension in the extensor tendon mechanism at a given joint is dependent on finger position -Deformities of late extensor mechanism disorders are reciprocal at adjacent joints -The extensor mechanism has far less tolerance for changes in tendon length (few mm) than the flexor system PREOPERATIVE CONSIDERATIONS FOR EXTENSOR TENDON RECONSTRUCTION -Patient education is essential, regarding complexity and duration of treatment. Avoid surgery in non-compliant patient -Potential functional gain vs. risk must be realistically assessed. Don‘t lose function for cosmesis -Do not reconstruct extensor mechanism if fixed joint deformity present. Splint / exercise to gain full passive motion. If unable, then consider 2-stage reconstruction: 1st joint release and splint/exercise, then tendon reconstruction -Many extensor mechanism imbalances will respond to non-operative treatment SPECIFIC PROBLEMS CHRONIC EXTENSOR TENDON DEFICIT PROXIMAL TO THE MP JOINT (APM): -Tendon transfer is most reliable treatment (see Ch.47) -Commonly used transfers in less severe injuries: function lost (transfer possibilities): EPL (EIP or PL), APL (BR), EDC (EIP or side-to-side adjacent EDC, FCU, FCR), ECRB (PT) -May consider tendon grafts between contracted ends if muscle contracture not irreversible and muscle can contract with adequate excursion -Complication: scarring. RX: exercise / splinting. Consider tenolysis if no better after several months. SUBLUXATION OF THE EXTRINSIC EXTENSORS AT THE MP JOINT LEVEL (see sagittal band injuries – Ch. 61) EXTRINSIC EXTENSOR TENDON TIGHTNESS (DORSAL TENODESIS) SXM: C/o inability to fully flex finger

PE: MP flexion imposes PIP extension and PIP flexion imposes MP extension Reason: Extensor tendon lacks excursion to permit simultaneous MP & PIP flexion. Usually from scarring / adherent tendon secondary to metacarpal fracture, soft tissue injury, tendon repair RX: Non-operative: At least 6 months hand therapy (exercise and static / dynamic splinting stressing simultaneous MP & PIP flexion usually successful) OPERATIVE: Tenolysis vs. extrinsic extensor release. -If just scarring / adherence, then tenolysis (see Ch 60); preserve sagittal bands. Retinaculum expendable -If tendon short or long scarring proximal to juncture, then Littler Extrinsic Extensor Release: central portion extensor excised over proximal phalanx. Preserve sagittal bands and central slip (stop 5-8 mm proximal to PIP). Use digital (not wrist) block; patient actively F/E to test. Extrinsic extensor extends MP and intrinsic extends PIP -Post-op for both: AAROM (F/E) immediately INTRINSIC EXTENSOR TENDON TIGHTNESS -See Ch. 15 -SXM: c/o inability to fully flex finger -PE: MP extension imposes PIP extension. PIP flexes easier with MP flexed. -Reason: similar to extrinsic tightness -RX: Non-operative: Hand therapy (as above) Operative: Resect lateral band, maintain central tendon SWAN-NECK DEFORMITY AND CLAW DEFORMITY -Swan-neck: PIP hyperextended, DIP flexed -Claw: MP hyperextended, PIP & DIP flexed DYNAMIC SIMILARITIES OF 2 COMMON COLLAPSE DEFORMITIES (DF = Dynamic Factor, C = Claw, SN = Swan-neck) -Both have hyperextended proximal joint & flexed distal joint -Both treated by re-establishing flexion (or limitation of hyperextension) at proximal joint -DF: Hyperextension of proximal joint, C: MP, SN: PIP -DF: Loss of proximal joint restraint, C: Intrinsics, SN: Volar plate -DF: Fixed point at proximal joint, C: Sagittal fibers at MP, SN: Central slip insertion -DF: Flexor tendon as deforming force at distal joint, C: FDS at PIP, SN: FDP at DIP -DF: Surgical correction, C: MP capsulodesis (Zancolli) or tendon transfer for MP flexion, SN: PIP tenodesis (Swanson or Littler) SWAN-NECK MANY ETIOLOGIES: (1) PIP injury with volar plate laxity, (2) spasticity – stroke & CP, (3) RA, (4) Fracture malunion, (5) Mallet finger with volar plate laxity, (6) Generalized laxity -Normal digit extension needs competent PIP volar plate to stop PIP hyperextension, o/w lateral bands displace dorsally which slackens distal tension and DIP droops

NON-OPERATIVE TREATMENT – Does not respond to conservative splinting / exercise; but non-operative measures may help with contractures / tightness OPERATIVE TREATMENT – (1) If secondary to mallet, fix mallet, (2) If secondary to fracture malunion, osteotomy, (3) If secondary to spasticity or non-compliant, PIP arthrodesis, (4) If RA, correct MP tendon imbalance or contracture before treating swan-neck, (5) If severe joint changes, then arthroplasty or arthrodesis -If supple swan-neck deformity, then 2 general methods: (1) Oblique retinacular ligament reconstruction, (2) Superficialis tenodesis at PIP. OBLIQUE RETINACULAR LIGAMENT RECONSTRUCTION: 2 general methods: (1) Original procedure using lateral band (Littler), (2) Modification using free tendon graft=SORL (PL, etc.) -Concepts same in both: (1) Tenodesis that passively tightens as PIP extends that is a check-rein to PIP hyperextension, (2) Volar to PIP & dorsal to DIP, (3) Passively tenodesis DIP into extension as PIP extends LATERAL BAND TECHNIQUE (LITTLER) -Expose ulnar dorsolateral aspect with long hockey stick incision. Leave ulnar lateral band attached distally and divide at M-T junction near MP. Dissect lateral band (sharply incise transverse retinacular fibers) and re-route it volar to Cleland‘s ligaments so its new path is volar to PIP and dorsal to DIP. -Secure proximally by 3 options: (1) Suture to flexor tendon sheath (A2 level), (2) Place through bony tunnel in proximal phalanx base and secure over button – ipsilateral side, (3) Spiral lateral band volarly and pass through bony tunnel on contralateral side over button TENDON GRAFT TECHNIQUE (SPIRAL OBLIQUE RETINACULAR LIGAMENT RECONSTRUCTION = SORL) (Thompson) -Expose as above. 2 bony tunnels made (with gouges and/or drills): (1) A/P at base of distal phalanx (protect germinal matrix and FDP insertion, (2) Transversely at proximal phalanx base. -Path of tendon graft (PL if available) is from dorsal distal phalanx passing ulnarly and volarly and spiraling obliquely across PIP to opposite side of base proximal phalanx. The path is SQ but deep to NV bundle. Proximal graft tied over button first. Then distal attachment tied ―dialing in‖ tension by slowly pulling graft until PIP at 20 degrees flexion with DIP at 0 degrees. SUPERFICIALIS TENODESIS (Littler) -Exposure: volar zigzag over proximal and middle phalanges. Resect flexor sheath between A2 & A4. Transect 1 FDS slip as proximal as possible and leave attached distally. Pass proximal end through drill hole (volar to dorsal) in proximal phalanx and tie over button. Stabilize PIP in 20 flexion with PC K-wire. -Disadvantage: May not rebalance DIP, leaving DIP lag. APM – Different situation need different techniques. -Lateral band technique preferred if patient also with intrinsic tightness (simultaneous intrinsic release). If other lateral band tight, release it too. Also preferred if multiple fingers (avoids multiple tendon harvests) -SORL preferred if DIP droop severe, long-standing, distal extensor attenuated -Superficialis tenodesis preferred if (1) stout repair needed (i.e. spastic), (2) multiple fingers (easy & quick)

POST-OP CARE (for all) -Dorsal block (PIP 20 degrees, DIP 0 degrees) splint and ROM. Gradually straighten PIP to 5-10 degrees is goal (not 0 degrees) LATE EXTENSOR HOOD ADHERENCE -Sxm: Loss PIP ROM -Etiology: Usually after laceration / fracture of extensor mechanism over proximal phalanx -RX: Exercise / stretch / splint. If fails, resect if central or 1 lateral band. If broad, extensive extensor tenolysis (but results poor) BOUTONNIERE DEFORMITY = flexed PIP & hyperextended DIP (see Ch. 61 for acute RX) -May be from trauma, RA, or OA. Central slip damaged and lateral bands sublux volarly. -Weak central slip and volar lateral bands mean all extrinsic and intrinsic tone flexes PIP. CLASSIFICATION: (1) Stage 1: Dynamic imbalance, passively supple, (2) Stage 2: contracture, (3) Joint changes. TREATMENT (APM) -Initially treat all with minimum 2-3 months splinting / exercise / stretching program: Goals – to get PIP 0 degrees with DIP fully flexed. Consider Joint-Jack splint. Surgeries are difficult and may not improve on non-operative RX. Most stage 1 & 2 respond to non-operative RX. -Occasionally stage 1 or 2 need surgery. If competent extensor insertion into middle phalanx base, then Eaton-Littler Procedure: Divide extensor mechanism transversely over middle phalanx at mid to proximal 1/3 junction distal to central slip insertion. Leave oblique retinacular ligament and lumbrical (on radial side) to control DIP. -If extensor insertion inadequate, do Littler-Eaton Procedure: As above but lateral bands rolled dorsally and sutured to central slip insertion,distal to PIP. OR consider Matev Procedure (see Ch. ?) -If central tendon and lateral bands inadequate, then Littler-Fowler Tendon Graft: Only if able to get PIP passively to 0 degrees. Strip of PL or EDQ passed through transverse bony tunnels, one at central slip insertion level and one at mid-proximal phalanx. Figure 8 tendon dorsally. -If fibrous ankylosis or arthritic joint, then fusion or arthroplasty. DIP JOINT EXTENSOR DISORDERS (MALLET FINGER DEFORMITY) (APM) -Splint first. If fails: (1) If no fx or OA, no swan-neck, then dorsal approach, tuck tendon, K-wire DIP at 0 degrees 4-6 weeks, splint as acute, etc. (2) If no fx or OA, but swan-neck, then SORL. (3) If fx, OA and symptomatic, then DIP arthrodesis

CHAPTER 63 - TENOSYNOVITIS -Either proliferative or reactive (stenosing tendovaginitis)

-Proliferative-relatively uncommon, erosive, may lead to tendon rupture. Examples: RA, amyloidosis, gout, septic tenosynovitis -Reactive tenosynovitis-thickened retinacular sheaths or tendon & fibrocartilaginous metaplasia. Examples: trigger finger, de Quervain, intersection syndrome, EPL, 4&5, ECU, FCR ANATOMY: 22 extrinsic tendons cross the wrist. 6 dorsal compartments (22,12,11) APL/EPB, ECRB/ECRL, EPL, EIP/EDC, EDM, ECU. 1st and 6th most commonly involved. 9 flexor tendons pass through the carpal tunnel. 4 annular and 3 cruciate pulleys. A1 & A3 over MCP & PIP, respectively. A2 over proximal phalanx and A4 over middle phalanx. C1 over proximal phalanx just distal to A2, C2 and C3 over middle phalanx straddling A4. If A1 sectioned, no less flexor function. A2 & A4 most important; bowstring & flexor function loss if sectioned. Thumb: 2 annular & 1 oblique pulleys. 1st annular over MCP, oblique over PP is continuous slip of adductor pollicis, 2nd annular over IP. PROLIFERATIVE TENOSYNOVITIS RA: hand & wrist tenosynovitis in >2/3. If dorsal tendons( prominent swelling. If flexor tendons(median nerve entrapment. Surgical appearance: abundant , red, ―angry‖ synovium, fibrinoid deposits (―rice bodies‖). Worst complication-tendon rupture, usually extensor; mainstay of treatment= prevention. Medical management: ASA/NSAIDs, hydroxychloroquine, gold, penicillamine, methotrexate, steroids. Rest, ice, splinting. For operative RX, see Ch 55. CRYSTALLINE TENDINOPATHY GOUT: disorder of urate metabolism. Monosodium urate has low solubility (crystallization and deposition in SQ, intra-articular, and tenosynovial locations. WBCs attempt to phagocytize and release lysosomal enzymes that produce intense synovitis( swelling, erythema, and pain. Left unchecked, disease results in gouty tophi=large SQ deposits of monosodium urate crystals, commonly in ear pinna and great toe. Medical control is mainstay of treatment: uricosuric agents (probenecid, sulfinpyrazone), xanthine oxidase inhibition (allopurinol), NSAIDs, intra-articular corticosteroids, and microtubule inhibitors (colchicines). Gout is called ―the great imitator‖-may masquerade as septic arthritis, septic flexor tenosynovitis, RA, neoplasm; can cause acute CTS. DX by labs, aspiration (crystal analysis, Gram stain). Other sites in hand: extensor tendons, mid-palm, dorsal IP & MP joints. If neglected, can lead to intratendinous infiltration, flexion contractures, tendon rupture, and skin ulceration. RX: colchicines and NSAIDs for acute attacks. Indications for surgery: restore joint and tendon mobility, decompression of median nerve, control of skin breakdown and infection, and removal of painful/disfiguring tophi. CALCIFIC TENDONITIS: release of calcium salts into intrasynovial space in joints or tenosynovial sheaths after acute, intensely painful synovitis. Presents with painful, swollen digit or wrist and marked decrease in motion—may mimic septic tenosynovits or cellulitis. Xrays may show fluffy calcium or be negative. RX: NSAIDs/splinting usually enough. Cortisone injection if no improvement. Rarely need surgical excision of large calcific deposits. DEPOSITION DISEASE AMYLOID DEPOSITION: deposition of protein, beta2-microglobulin, most commonly in renal dialysis patients. Cystic lesion in carpal bones and destructive arthropathy in wrist and IP joints, tenosynovitis(CTS, trigger fingers, flexion contractures, tendon rupture. Present with

chronic swelling along tendons without significant pain, warmth, erythema. RX: surgical tenosynovectomy. Go proximal to wrist crease in CTR. Recurrence uncommon. OCHRONOSIS: deposition of homogentisic acid in joints and soft tissues and tendons, may cause stenosing tenosynovitis. Caused from rare autosomal recessive deficiency in the enzyme homongentisic acid oxidase. SARCOID: A systemic immune mediated granulomatous disease – affects lungs, spleen , LN, bones, joints, tenosyovium. X-rays: well-defined cystic granulomatous lesion in the phalanges. More common in women, blacks 10x > whites. RX: surgical tenosynovectomy and systemic corticosteroids. STENOSING TENDOVAGINITIS HISTOLOGY: degeneration and vascular prolifieration, but lack of inflammatory cells. ETIOLOGY: Not completely understood. Trauma probably has some role (higher incidence in dominant hand). Several studies show relationship to heavy gripping activities. However, more common in women, and peak incidence 55-60 y.o. TRIGGER DIGITS -One of most common hand problems. Painful catching and locking. Can lead to secondary contractures. PATHOLOGY: disproportion in size between flexor tendons and A1 pulley. Fibrocartilaginous metaplasia of A1 pulley and tendon from repetitive, compressive loads. CLASSIFICATION: Grade I (pretriggering) – pain, tender over A1 pulley. H/o catching but none on PE. Grade II (active) – catch, but active extension possible. Grade III (passive) – IIIA- catching requiring passive extension. IIIB – inability to flex Grade IV (contracture) of PIP DEMOGRAPHICS: -Women 2-6x men -Several fingers not unusual -Secondary-RA, DM (reduced success with injection) H & P: often pain at PIP, trigger DDX: true MCP lock, tumor of tendon or sheath, loose body in MCP, anomalies of sesamoid, entrapment of intrinsic tendon on irregularity of metacarpal head, deQuervain‘s, EPL stenosing tendovaginitis. Enlargement of FDP can trigger at A3 and lead to persistent symptoms after release. Up to 22 % triggers in RA from FDP entrapment at superficialis decussation. RX: 1-2 trials of corticosteroid injection (70-90% success in primary, 50% in DM). 0.5 cc plain lidocaine with 1cc soluble corticosteroid (triamcinolone, betamethasone, or dexamethasone), 27-gauge needle, prep hand with povidone-iodine or alcohol, hyperextend digits. Palpate metacarpal head and spray skin with ethyl chloride for 10 seconds. Needle introduced into flexor tendon at 45 degrees, inject and slowly withdraw and feel relief of resistance when needle emerges from tendon. If refuse injection, may splint MCP at 15 degrees x 2 weeks. Release if fail. SURGICAL TECHNIQUE:

-Forearm tourniquet. Infiltrate skin and sheath with 5cc 1% plain lidocaine. 1 cm longitudinal incision between proximal and distal palmar creases for index, distal to distal creases for ulnar 3 digits, and 1.5 cm transverse incision at MCP crease for thumb. Alternatively, 1-1.5 cm transverse incision at proximal palmar crease (index), distal crease (ring & small), and ½ between (middle). Bluntly spread longitudinally after skin incised; retract subQ fat, palmar fascia, and neurovascular bundles to expose A1 pulley. Divide A1 with 11 blade/scissor. Do not cut A2 (continuous with A1 in 40-65%). Patient should move digits to demonstrate no triggering. Immediate ROM post-op. COMPLICATIONS: -Nerve injury-needs repair. If A2 sectioned and bowstringing, need pulley reconstruction (see Chapter 60) PERCUTANEOUS TRIGGER FINGER RELEASE: -Alternative technique, done in office -Prep, hyperextend MCP over rolled towel. Ethyl chloride and lidocaine local anesthesia. 19gauge needle placed in A1, placement in tendon confirmed by patient slightly flexing digit and noting needle motion. Needle withdrawn to exit tendon and needle bevel aligned longitudinally. Needle swept to incise pulley; complete when grating disappears. Patient flexes digit to demonstrate no triggering. CONGENITAL TRIGGER THUMB: -Presentation: child with thumb locked in flexion -DDX: congenital trigger thumb (most common), congenital clasped thumb, absent or aberrant extensor tendons, arthrogryposis, spasticity. -Pathology is Notta‘s node=nodular thickening in tendon, not sheath thickening as in adults -Bilateral in 25-33% -No association with other congenital anomalies -Rarely, other digits involved -RX: surgery needed -SURGICAL TECHNIQUE: Transverse incision made over nodule at MCP crease. Protect neurovascular bundles (lie very superficially under skin). Blunt dissection done to A1 pulley. Divide pulley and lift tendon to ensure full thumb motion. Do not excise or reduce tendon nodule. DEQUERVAINS’S DISEASE: -HX: Radial wrist pain, aggravated by thumb movement. Usually women in 4-5th decades. -PE: Locally tender and swollen over 1st DC, 1-2 cm proximal to styloid. Positive Finkelstein test. -DDX: Intersection syndrome, basal joint & other wrist joint OA (may coexist), scaphoid fracture. ANATOMIC VARIATIONS: -―normal (1 EPB, 1 APL, 1 tunnel) anatomy‖ in only 20%. Multiple tendon slips and osteofibrous tunnels usual. EPB absent in 5-7%. TREATMENT

NONOPERATIVE: Injection 1-2x‘s, success 50-80%. Splinting adds nothing to injection (Weiss JHS 1994). TECHNIQUE OF INJECTION: -1cc dexamethasone/0.5 cc 1% plain lidocaine, 27-gauge needle. Palpate tendons while patient abducts/extends thumb. Spray with ethyl chloride. Enter 1 cm proximal to styloid, inject while backing out. Resistance decreased as needle exits tendon. Redirect dorsally to EPB. May repeat x 1 in 4-6 weeks. SURGICAL TECHNIQUE: -Local anesthesia, forearm tourniquet. 2 cm transverse skin incision made over 1st DC 1 cm proximal to radial styloid tip. Protect 1-3 radial sensory nerves which lie directly superficial to 1st DC. Radial artery is deep to tendons. Expose annular ligament and sharply incise (not excise) with 15 blade. Explore for all slips and tunnels, lift tendons and ensure decompression from musculotendinous junctions to 1 cm past sheath. Specifically identify EPB by lifting tendon and noting thumb MCP extension. Debulk tenosynovium if thick and opaque. Replace tendons and have patient move thumb and note no compression. Soft dressing, ROM immediately. COMPLICATIONS: -STEROID INJECTION: 5-10% risk of subQ atrophy, fat necrosis, and/or depigmentation. Decreased risk with more water-soluble steroid, i.e. dexamethasone. Usually resolves within a year, but if severe, may need skin or fat grafts. -SURGICAL: Injury to radial sensory branch (either by cutting (neuroma), or vigorous retraction (neuroma in situ) may cause more pain than original condition. Treat with microsurgical nerve repair or resection and placement of nerve end into muscle proximally. -Incomplete relief after surgery is not uncommon. May be from incomplete release-try lidocaine test; may have to re-explore. May be from basal joint OA-try lidocaine test. Hypertrophic or painful scars may need to modified with Z-plasty. Rare painful tendon subluxation may require pulley reconstruction with slip of retinaculum or brachioradialis. OTHER STENOTIC CONDITIONS OF TENDONS AT THE WRIST: INTERSECTION SYNDROME: Pain and swelling (redness and crepitus if severe) where 1st and 2nd dorsal compartments cross 4 cm proximal to wrist joint. Basic pathology is tenosynovitis of 2nd DC. 1st DC originates ulnar to 2nd, passes dorsally, then inserts radial to 2nd. Associated with repetitive motions (rowing, weight lifting). RX: Activity modification, splinting (wrist in 15 degrees extension), ice, NSAIDs. Corticosteroid injection into 2nd DC. Surgery if fails. -SURGERY: Incision over 2nd DC starting at RC joint and going proximally. Protect radial sensory nerves. Open 2nd DC sheath, elevate and inspect tendon and debride frayed or degenerated fibers. Do not close sheath. Splint in neutral and resume ROM after 1 week. EPL: -Rarely occurs, but if does, needs rapid treatment to prevent rupture -HX: Pain with thumb IP motion, possible triggering -PE: Tender, swelling, crepitus at Lister‘s tubercle.

-RX: SURGERY: 2 cm incision over Lister‘s. Protect radial sensory nerves. Open 3rd dorsal compartment and elevate and inspect tendon and debride frayed or degenerated fibers. Close sheath and replace EPL out of tunnel radial to Lister‘s. Resume ROM. 4TH & 5TH EXTENSOR COMPARTMENTS: -Usually associated with RA. Usually EDC tendons of index and small digits because acute tendon angle. -PE: Tender/swelling over compartment. Increased pain with resisted MCP extension while wrist flexed. -RX: Splinting, ice, NSAIDs. Corticosteroid injection. ECU: -HX: Not uncommon cause of ulnar-sided wrist pain. Usually twisting injury. Pain may interfere with sleep. May have dysesthesia. -PE: Pain with all wrist motions, increased with resisted extension/ulnar deviation. Crepitus and swollen ECU sheath. Must differentiate from ECU subluxation: palpate ECU while patient flex/pronate/ulnar deviates wrist from extended/supinated position. May coexist with TFC tear, DRUJ OA, CTS. -RX: Extension splint, ice, NSAID‘s. Diagnostic/therapeutic corticosteroid injection. Surgery if fails. -SURGERY: Incise fibro-osseous ECU canal through 3 cm curvilinear incision over DRUJ. Protect ulnar sensory nerve. Elevate and inspect tendon and debride frayed or degenerated fibers. No need to reconstruct retinaculum. FCR: -Prone to stenosis: sharp angulation across trapezium (inserts on base of index metacarpal) -DDX: ganglion, basal joint OA, scaphoid fracture, deQuervain -HX: Pain at palmar wrist crease over scaphoid tubercle. Typically woman in 5th decade. Not usually with h/o trauma. -PE: Tender FCR, swelling. Increased pain with resisted wrist flexion/radial deviation. -RX: Splinting, ice, NSAIDs. Corticosteroid injection. Surgery if fails. -SURGERY: 3cm incision over FCR. Protect palmar cutaneous branch median nerve and radial sensory nerves. May need to elevate thenar muscles. Open sheath proximal to fibrous tunnel and distally beyond trapezial tubercle. Elevate and inspect tendon and debride frayed or degenerated fibers. Debride trapezial groove of rough, sharp edges/osteophytes with rongeur. Do not close sheath. Resume ROM after 1 week. CHAPTER 64 – THE BURNED HAND (Achaer) -Hand burns are common 4 COMPONENTS OF EARLY TREATMENT: (1) determine burn depth, (2) determine need for escharotomy, (3) splint, (4) wound care EVALUATION OF DEPTH OF INJURY:

-Partial thickness burn: red; +/- blistering, hypersensitive -Full thickness burn: leathery, white, +/- insensitive, thrombosed veins -Debride by tangential shaving; when bleeding occurs, this is the level of viable skin / end of burn level DETERMINING NEED FOR ESCHAROTOMY: -The most important burn management principle is perfusion by (1) fluid resuscitation, (2) removing obstruction to mechanical flow. -Usually with marked edema which progresses for 36 hours. Also circumferential burns can produce a constricting band. If tight band or tight compartments, consider escharotomy / fasciotomy. Check subeschar and compartment pressure; If > 30 mm Hg, then release (capillary filling pressure = 25 mm Hg) ESCHAROTOMY TECHNIQUE -If necessary, may be performed at the bedside (vs. fasciotomies which MUST be done in O.R.) -Use IV sedation, analgesics, possible local anesthetic, electrocautery -Radial incision from acromion tip, to lateral edge of antecubital flexion crease, to radial styloid, to radial aspect of thenar eminence, to mid-lateral thumb -If blood flow not restored, then add medial ulnar incision, from axilla to medial epicondyle, ulnar aspect of forearm, mid-lateral hand and little finger -Index, middle, and ring fingers may be released with mid-lateral incision on the ulnar aspects -Interossei may be released through vertical incision between metacarpals and bluntly spread deeply to palmar interossei -In deep and electrical burns, fasciotomy is necessary (see Ch. 24) -Post-op: leave wounds open, no constricting dressing. Elevate. Fingers heal by secondary intention; may need later skin grafting for arm. SPLINTING -Extremely important to splint hand in ―anticlaw‖=safety position with thumb abducted on day of injury with customized thermoplast splint. Immediate A & PROM and elevation. Hand therapist is paramount. -If deep injury to PIPs, consider K-wire fixation of PIPs at 0 degrees x 2-3 weeks LOCAL WOUND CARE -Daily whirlpool, debridement -Silver sulfadiazine (Silvadene) 1%, gauze EXCISION AND GRAFTING -If burn unlikely to heal in 2-3 weeks, then skin graft -1st tangentially excise burned skin until brisk bleeding from ALL tissue. Use Goulian knife (Weck Co.), a single-edged razor with a guard -For hemostasis, consider using epinephrine (1:10,000) soaked sponges, electrocautery, or fibrin glue -STSG (non-meshed better). See Ch. 57

TYPES OF BURNS (thermal, chemical, electrical): THERMAL BURN -Most common -Usually dorsum of hand because (1) thinner skin, (2) During burn, hand is covering face or in a fist CHEMICAL BURN -Irrigate as soon as possible -Consult a toxicologist for any chemical-specific treatment -Hydrofluoric (HF) acid burn: common injury, usually fingertips, HF is ubiquitous in industry (cleaner, rust remover). Calcium, magnesium neutralizes HF. If extensive, need admission to burn unit. Deliver by radial (2 g calcium gluconate in 200 cc D5W over 4 hrs) or brachial (3 g calcium gluconate in 250 cc D5W over 4 hrs) arterial line. Usually repeat in 6-8 hrs. Or SQ 10% calcium gluconate at 1cc/cm2 with 25 gauge needle; or 2.5% calcium gluconate gel. If after 2nd infusion there is blue-black under nail bed, then remove nail and apply dressing with 10% calcium gluconate. Unroof and debride bullae/avascular tissue. If > 2% BSA exposed, then 1 g calcium choride IV at 75ml/hr. ELECTRICAL BURN -Most burns from electrical short are flash burns, which are fairly superficial and treated same as thermal burns -True electrical conduction burns are completely different, and represent severe injuries with poor prognosis. Patients have significant, permanent disability -Usually small entrance and exit wounds with massive damage to vessels, nerves, muscles -All need emergent fasciotomies, debridement (usually 2-3 x‘s) -Technetium-99 scan can show devitalized muscles -For child, reconstruct. For adult with unilateral, major injury; consider amputation. If bilateral, save least injured, dominant if equal, consider transferring viable parts. -May need flaps, vessel / nerve grafting, etc. REHABILITATION -Hand / occupational therapy is paramount: ROM, web spacers, compression to control edema RECONSTRUCTION FOR BURN CONTRACTURE / DEFORMITIES: CLAW DEFORMITY -2 priorities: (1) obtain MP motion, (2) satisfactory PIP position -Stiff PIP (burn boutonniere) does not do well with tendon / joint reconstruction; usually need to fuse at 60 degrees. Difficult digital dissection around N/V. Rarely DIP also needs fusion -MP motion requires flap coverage (pedicled groin, free temporalis, or distal forearm fascial flap) at 1st stage, then joint release in 2nd stage (collateral release, capsulotomies, volar plate release), immediate ROM -Treat wrist flexion contracture with incision of volar scar and skin graft. Splint in extension. PALMAR CONTRACTURE -Uncommon; caused when child or adult with seizure grabs a hot object -Treatment: release / dissect scar; resurface with FTSG (abdomen). Flaps usually not needed. Splint digits 2-5 in slight hyperextension, wrist in slight extension.

WEB SPACE DEFORMITIES (3 types): WEB SPACE CONTRACTURE -Most common; difficult to prevent. Treatment (APM): V-M plasty. Actually make ―x‖ cut with additional vertical incision from center down. Flap is not raised. Move apex from top center down to bottom. Z-plasty less severe cases. ADDUCTION CONTRACTURE = contracture in 1st web space that also includes muscle fibrosis (web space contracture is only skin). Treatment: Divide fascia and muscle until adequate space. If no deeper structures exposed, cover with skin graft; if exposed, then flap (APM: groin flap) BURN SYNDACTYLY – Rare. Treatment: skin grafts / local flaps HYPERTROPIC SCAR AND CONTRACTURE BANDS -Treatment: excise and repair with local flaps (i.e. z-plasties) or FTSG if large area RECONSTRUCTIVE PROCEDURES FOR AMPUTATION DEFORMITIES: PHALANGIZATION-s/p amputation, can lengthen digits by deepening web spaces by V-M plasty and skin grafts on lateral aspects of digit MITTEN DEFORMITY – No 1st web space, thumb may be short. Treatment: remove 2nd ray and cover the space with skin graft or thin flap to make adequate web space. The resected 2nd ray may be used to augment the thumb THUMB RECONSTRUCTION -See Chapters 66 & 40 DISTRACTION OSTEOGENESIS -See Chapter 20 NAIL BED DEFORMITY -Dorsal digital burn contractures cause eponychial retraction and proximal nail exposure and breakdown. Treatment: transverse incision parallel to and a few mm proximal to nail, then bilateral proximally based flaps (in shape of floppy dog ears), these are rotated 90 degrees to cover dorsal gap and secured with 5-0 or 6-0 chromic sutures ELBOW -To prevent contractures, important to splint at 0 degrees at night, and ROM during day. If contractures still occur, may need surgical release. (see Chapter 22) -Severe burns associate with heterotopic ossification (H.O.). If occurs, may need excision: posterior incision, ulnar nerve anterior transposition and H.O. excised; may require collateral ligament excision; excise radial head if rotation limited. Early ROM. AXILLA

-To prevent contractures, ROM / pulleys immediately. If still contract, release by z-plasty; triangular transposition flap if able; if not latissimus dorsi fasciocutaneous flap CHAPTER 65 – FROSTBITE (House, Fidler) - 2 major groups of cold injuries: FROSTBITE = damage to tissue from low temperatures which involves ice crystal formation in tissue. TRENCH FOOT, IMMERSION FOOT, CHILBLAINS = cold injuries from exposure to above freezing temperatures, usually wet, often with irreversible NV changes. - Frostbite leads to 2 major pathophysiologic events: 1) osmotic gradient from extracellular ice crystals produces dehydration, electrolyte imbalance, and metabolic disorder; 2) vascular impairment from endothelial injury, thrombus formation, hemoconcentration, increased viscosity and sympathetic tone. MANAGEMENT OF FROSTBITE - Restore core body heat (External warming devices/blankets, Warm PO fluids) - Manage shock, malnutrition - Rapid rewarming of frozen extremity (40-44 degree C water bath, Sedation and analgesics, Continue rewarming until digital flush appears) - Triple-phase Tc99 bone scan. If no digital blood flow on acute-phase scan, follow TPA protocol (see below) - Tetanus prophylaxis - Open dressing technique (Keep blebs intact, Topical aloe vera (Dermaide Aloe) q 6 hrs, Silvadene to ruptured blebs and mummified skin) - Oral ibuprofen 12 mg/kg/day (200 mg QID) - Antibiotics only for confirmed infection - Physical therapy BID (Whirlpool debridement, Gentle AROM, Splint if contractures) - Await clear demarcation before amputation or surgical debridement (can take 2-3 months. DO NOT rush into surgery!) TPA PROTOCOL -TPA IV bolus 0.15 mg/kg, then 0.15 mg/kg/hr x 3 hrs, not to exceed 100 mg total dose. TPA stopped if obvious clinical improvement. If uncertain, repeat bone scan. If blood flow still impaired, then resume TPA at same rate until 100 mg given. After TPA, then IV heparin for PTT 2x control. Coumadin started on day 2 for 4 weeks. Dextran also given. MANAGEMENT OF SEQUELAE OF FROSTBITE: MUMMIFIED DIGITS - Do not perform premature amputation, but wait for clear demarcation and mummification, then amputate preserving maximal functional length. Resect sufficient bone to permit loose skin closure. If uncontrolled local infection, perform open guillotine amputation and allow to close secondarily. NECROSIS OF CRITICAL SKIN – may need rotational local skin flap, full-thickness pedicle flap, free or rotational fasciocutaneous flap (ulnar or radial artery forearm flap)

VASOSPASTIC SYNDROMES – sympathetic overactivity and cold sensitivity with pain, vasoconstriction, skin changes. RX: consider regional sympathectomy or distal sympathectomy of digital vessels (by stripping adventitia from digital vessels in distal palm) INTRINSIC MUSCLE ATROPHY & FIBROSIS - from ischemic injury. RX: Early, active rehab and splinting. In extreme cases, may need release of fibrosed muscle and joint contractures. FROSTBITE OF THE JUVENILE HAND – Major lesion is premature closure of phalangeal epiphyses due to direct injury to chondrocytes. Not evident until 6-12 months after cold exposure. Symptoms: pain, stiff, weak. Eventually DJD, short/angled digits (usually 5th DIP, radially), skin redundant, joint laxity. RX: Few require surgery. If needed, consider epiphyseal arrest, arthrodesis, angular osteotomy. CHAPTER 66 – THUMB RECONSTRUCTION (Kleinman, Strickland) -If most of proximal phalanx is retained, no need for lengthening or web space deepening -Thumb sensitivity extremely important -Thumb function highly dependent on CMC motion, but not MP or IP motion PART I: THUMB RECONSTRUCTION FOR CONGENITAL ABSENCE

CONGENITAL FAILURE OF THUMB FORMATION -Major difference between congenital and traumatic thumb loss: in congenital case, child has reduced or absent cerebrocortical representation -5 Types (Buck-Gramcko): (1) Type I: Thumb size diminished, but otherwise not missing parts, (2) Type II: Reduced or absent thenar musculature, web space contracture, ligamentous instability, (3) Type III: More severe aspects of Type II, plus variable bony defects, IIIA: CMC present, IIIB: CMC absent (4) Type IV: Pouce flottant = floating thumb. 1st metacarpal, trapezium, and scaphoid absent. 1-2 neurovascular pedicles pass into thumb, (5) Type V: Complete thumb absence POLLICIZATION FOR CONGENITAL FAILURE OF FORMATION: THE APLASTIC THUMB AND THE ―POUCE FLOTTANT‖ -Types IIIB, IV, and V require pollicization -Incision starts at proximal digital crease of the index finger palmarly and converges at a 70degree angle dorsally (apex proximal). Make a dorsal straight incision beginning at a point 1/3 ulnar to the mid-lateral line and extend it distally to the PIP. Make another curvilinear palmar incision from a midpoint of the digital crease proximally to the distal wrist crease with a radial concavity. -Perform the palmar dissection first. Cross-clamp and ligate the bifurcation of the common digital artery to the long finger. Mobilize both neurovascular bundles and at least 1 major dorsal vein.

-Resect part of the index metacarpal: the ideal lengthen of the pollicized digit is tip to the PIP of the long finger. If the index finger is normal, then perform subcapital resection of the entire metacarpal. -Release tourniquet to allow washout and check perfusion of digit -Hyperextend the MCP (of the pollicized digit) before seating it. 2 non-absorbable braided sutures are placed through the flexed metacarpal head along the radial and ulnar collateral ligaments. Pass the sutures through the distal carpus to loosely align the new thumb at 160 degrees pronation. -Internal fixation is usually not needed; stability is controlled by tendon tension; heals by fibrous ankylosis. Final resting posture of metacarpal should be 40 degrees abduction, 15 extension, 120 pronation. MOTORING THE POLLICIZED DIGIT -Shorten the EIP and use as primary thumb extensor. Redirected EDC palmarly to act as an abductor. -Abduction and adduction achieved by transferring the first dorsal interosseous (abductor indicis) and first palmar interosseous into the lateral bands of the index finger -Not necessary to either shorten the flexor tendons or remove the lumbrical -Be aware of potential anatomic variations. If no abductor indicis, distal and palmar advancement of then index EDC. In absence of extrinsic extensors, use EDQP for thumb extension. In absence of extrinsic flexors, use FDS IV. AFTERCARE -Long arm thumb spica cast (see above for posture), change to removable splint at 3 weeks and start AAROM & gentle PROM AGE CONSIDERATIONS -Controversial. APM: 1 year of age PART II: THUMB RECONSTRUCTION FOLLOWING PARTIAL OR COMPLETE TRAUMATIC LOSS -Level of thumb loss is most important factor in determining appropriate procedure of thumb reconstruction -LEVELS: (1) Distal to IP, (2) Middle: from MCP to IP, (3) Proximal: 1st metacarpal. AMPUTATION THROUGH THE DISTAL THIRD OF THE FIRST RAY (distal to IP) PALMAR ADVANCEMENT FLAP (MOBERG) (See Ch. 58) -Indications: Volar pulp loss, less than 2.5 cm (or 50% of pad) CROSS FINGER FLAP (See Ch. 58) -Can resurface entire palmar surface of the volar pulp -Use dorsal skin of index proximal phalanx


RADIAL SENSORY-INNERVATED CROSS-FINGER FLAP -Flap carries a sensory branch of the radial nerve AMPUTATION THROUGH THE MIDDLE THIRD OF THE FIRST RAY (from MCP to IP) -Options: 1st web space deepening, bone lengthening , toe transfers. DISTAL PORTION OF PROXIMAL PHALANX Phalangization = deepening the first web space and creating a widened thumb-index interval Z-PLASTY: Indication: (1) at least ½ of proximal phalanx remains, (2) the skin is minimally scarred, (3) the first metacarpal is mobile, (no muscle contracture) SIMPLE Z-PLASTY: Incision from thumb proximal digital crease to 1cm proximal to the index proximal digital crease (see Ch. 58) 4-FLAP Z-PLASTY OF THE THUMB WEB: (see Ch. 58) PHALANGIZATION OF THE FIRST METACARPAL WITH DORSAL ROTATIONAL FLAP COVERAGE: -Make a continuous linear dorsal to palmar incision through the first web, beginning dorsally at the trapeziometacarpal joint; to the base of the thenar eminence on the palmar side -Dissect just ulnar to the EPL, protecting the radial nerve. Strip the 1st dorsal interosseous from the 1st metacarpal. Identify the radial artery between the 2 heads of the 1st dorsal interosseous just beyond the trapeziometacarpal joint. Follow and identify and protect the princeps pollicis artery. -Divide the adductor and assess the 1st ray mobility; the opponens pollicis may need to be stripped. Perform CMC joint release through a palmar incision or trapezial excision as needed. -The thumb is stabilized in the corrected position by 2 nonparallel K-wires or an external fixator -Make a paper trial of the flap. Incise the flap from the dorsum of the hand from the ulnar 1st web across the MCP joints of the index and 3rd fingers, then proximally to the base of the 4th metacarpal -Suture the flap into place. Defect covered with full-thickness from the groin or a split-thickness skin graft. -Drain 24-48 hours, digital motion started at 2-3 weeks, pins are removed at 4-6 weeks. FIRST WEB SPACE DEEPENING WITH CROSS-ARM FLAP COVERAGE -Release 1st web space and maintain with K-wires or external fixator. -Triangular flap fashioned from upper arm; at 3 weeks flap divided and 2nd triangular flap fashioned to cover the palmar defect.

PROXIMAL PORTION OF PROXIMAL PHALANX DEGLOVING INJURY: radial island forearm flap or tubed abdominal pedicle flap followed by a neurovascular island pedicle flap (critical to provide sensitivity to the thumb) INJURED OR PARTIALLY AMPUTATED DIGIT: TRANSFER OF AN INJURED DIGIT TO THE THUMB -Add length and also widens and deepens the first web space POLLICIZATION OF AN INDEX FINGER STUMP -Incise circumferentially around the base of the index finger palmarly, and dorsally make a ―V‖ over the 2nd metacarpal. -Dissect palmarly and identify neurovascular bundles to the index and radial aspect of the long finger. Clamp and ligate the digital artery to the long finger and tease apart the digital nerves to the palm. -Divide the transverse intermetacarpal ligament and dissect through the 2nd intermetacarpal space from both the dorsal and palmar aspects. -Leave the flexor and extensor tendons undisturbed -Subperiosteally expose the index metacarpal. Divide the metacarpal obliquely at the base. The amount of additional metacarpal to be removed will depend on level of the thumb loss, but is usually just proximal to metacarpal neck. The index finger should be mobile -Thumb stump is prepared by removal of scar. Fashion a bone peg out of the removed 2nd metacarpal -Transfer the digit and secure the bone with oblique K-wires or compression plate -Transpose the lateral skin flap into the cleft POLLICIZATION OF THE STUMP OF THE LONG FINGER -Similar to index finger except extensor tendon divided and repaired to the EPL -Index and ring fingers approximated by suturing the deep transverse metacarpal ligaments ―COCKED-HAT‖ FLAP -Use 2.5 cm iliac bone graft to lengthen -Has largely fallen into disuse at this time FIRST METACARPAL LENGTHENING (see ch. 20) -Rarely a 1st choice operation, but may use if other options not feasible -Prerequisites: 1st metacarpal with at least 2/3 good soft tissue cover -Usually combined with phalangization technique (Z-plasty) -If remnant of thumb proximal phalanx present, then place a longitudinal K-wire (0.062 inch) across the MCP joint to prevent progressive MCP flexion by myodesis -In adults, APM: adjunctive intercalary corticocancellous iliac crest bone graft once appropriate metacarpal length has been achieved -Can achieve 3-4 cm on length.

OSTEOPLASTIC THUMB RECONSTRUCTION (=bone graft covered by tubed pedicle flap) TECHNIQUE: STAGE I: Raise a groin flap that includes the superficial circumflex iliac artery (see ch. 58). Also harvest a tricortical bone graft from the iliac crest. Fix the bone with longitudinal or oblique pins. STAGE II: At 4 weeks, flap should be partially divided and superficial circumflex iliac artery ligated. Raised extended neurovascular island flap from the ulnar aspect of the long finger. COMPOSITE RADIAL FOREARM ISLAND FLAP (see ch. 37) AMPUTATION THROUGH TTE PROXIMAL THIRD OF THE FIRST RAY (=proximal to MCP) -Pollicization of injured index finger is best option (see above for technique) -If other digits too severely injured, then consider toe transfer (see ch. 40) -Pollicization returns better sensation and fine motor, but toe transfer is stronger. Discuss options with patient LOSS OF THUMB AND ALL DIGIT INJURIES = METACARPAL HAND -Options: (1) Below Elbow Amputation and immediate prosthetic fitting, (2) Phalangization PHALANGIZATION OF THE METACARPAL HAND (produces crude ―lobster-claw‖ hand) TECHNIQUE -Make dorsal to palmar incision over 2nd metacarpal stump. Rotation flaps planned -Excise tendons and nerves proximally -2nd metacarpal and 50% 3rd metacarpal and trapezoid resected. -Dorsal rotation flap to cover web space, FTSG to cover donor area -Web spreading splint CHAPTER 67 – GANGLIONS (Alexander Angelides) CLINICAL CHARACTERISTICS: Most common soft tissue mass of the hand (50-70%), usually attached to joint capsule, tendon, or tendon sheath. More prevalent in women, 2-4th decades. DDX: tenosynovitis, lipomas, tumors. May increase in size, fluctuate, or resolve spontaneously. MICROSCOPIC ANATOMY: Walls made of compressed collagen fibers, no epithelial cells. Content is mucin made of glucosamine, albumin, globulin, hyaluronic acid. PATHOGENESIS: ―Etiology and pathogenesis remains obscure.‖ Trauma leading to mucin production and one-way valvular mechanism postulated. NONOPERATIVE: If asymptomatic, explanation and assurance of nonmalignant nature is often all that is required. If symptomatic, may intiate with puncture, aspiration, and injection of lidocaine/corticosteroid. Surgery if fails. OPERATIVE TREATMENT: Excision with stalk/capsule/sheath. Do not close capsule. Recurrences rare with proper excision. DORSAL WRIST GANGLION

CLINICAL CHARACTERISTICS: Most common hand/wrist ganglion (60-70%), usually from scapholunate ligament. Review x-ray to r/o intraosseous component. OPERATIVE TECHNIQUE: Flex wrist, transverse incision, dissect between and 3rd and 4th DCs. Excise cyst with 1 x 1 cm window of capsule. Splint x 1 week, then ROM to avoid stiffness. Arthroscopic excision is another option (see chapter 10). Re-excise if recurs. OCCULT DORSAL CARPAL GANGLION: Flex wrist to accentuate cyst. R/o other causes of pain: SL sprain, instability. Consider MRI. If other causes excluded, start with steroid injection. If fails, explore, excise, conside PIN excision. VOLAR WRIST GANGLION CLINICAL CHARACTERISTICS: 2nd most common hand/wrist gangion (18-20%), most arise from radiocarpal joint, pass between FCR & APL, and intertwine with radial artery. May extend to thenar muscles, FCR, carpal tunnel, 1st DC. Another possible origin: scaphotrapezial joint. OPERATIVE TECHNIQUE: Assess Allen‘s test preop. Using loupes, longitudinal incision, be prepared to extend into carpal tunnel. Incise distal forearm fascia proximal to cyst, identify radial artery. Protecting artery, excise cyst with 3-4 mm capsular window. Splint x 1 week, then ROM. COMPLICATIONS: Radial artery injury treated with microvascular repair (APM) or ligation. Counsel patient that unpleasant scar not uncommon and often defy ―plastic‖ revisions. VOLAR RETINACULAR (FLEXOR TENDON SHEATH) GANGLION CLINICAL CHARACTERISTICS: 3rd most common hand/wrist ganglion (10-12%), arises from A1 pulley. 3-8mm firm, tender mass, does not move with digital motion. TREATMENT: Needle puncture, steroid injection, and massage. Surgery if fails. OPERATIVE TECHNIQUE: Transverse or ―L‖ incision. Approach like trigger digit, excise ganglion and portion of A1 pulley. MUCOUS CYST CLINICAL CHARACTERISTICS: =Ganglion cyst of DIP, usually 5-7th decade. May have longitudinal grooving of nail from pressure on nail matrix. 3-5 mm, usually lies on one side of extensor tendon, and lies between dorsal distal crease and eponychium. X-ray: DIP OA. OPERATIVE TECHNIQUE: ―L‖ shaped incision with apex at lateral aspect of DIP crease. Skin that cannot be separated from the cyst wall is elliptically excised. Cyst and joint capsule from collateral ligament to extensor tendon excised on both sides, leaving DIP exposed. Excise osteophytes, protect insertion of tendon and nail matrix. If skin excised, cover with full-thickness skin graft or rotate and advance dorsal skin flap. Splint 2 weeks. CARPOMETACARPAL BOSS CLINICAL CHARACTERISTICS: = Traction osteophtic vs osteoarthritic spur at the 2nd or 3rd CMC joint. A firm, bony, non-mobile, tender mass is visible and palpable , especially with flexed wrist. More common in women, right hand, 3-4th decades. May be asymptomatic or cause

considerable pain and aching. Ganglion present in 30%. X-ray: ―Carpal boss view‖=30 degree supinated from lateral and 20 degrees ulnar deviation. SURGICAL TECHNIQUE – CMC BOSS EXCISION: Transverse incision over CMC. Protect sensory nerves. Retract EDC and EIP. If ganglion present, excise with capsule. Approach CMC joint through longitudinal incision (ECRL & B insert on radial aspect of 2nd & 3rd metacarpal bases, respectively). Osteophyte often bridges and obscures CMC joints; rongeur protuberance and joint will become identifiable. Excise osteophytes to normal cartilage, leave no abnormal abutting surfaces. Goal is to identify ―4 corners‖: 2nd and 3rd metacarpals, trapezoid, and capitate. If significant OA remains, may need CMC fusion. Repair ECRB & L if needed. POSTOPERATIVE CARE: Cast 4-6 weeks. PIP CYST CLINICAL CHARACTERISTICS: Similar to mucous cyst, 3-5 mm ganglion arises from joint capsule and pierces between central slip and lateral band. May be tender and interfere with motion. OPERATIVE TECHNIQUE: An ―L‖ incision (90 degree with apex at lateral aspect) made dorsally. Lateral band released from lateral margin. Cyst and entire joint capsule and synovial lining excised from collateral ligament to central slip on both sides. Immediate ROM. EXTENSOR TENDON GANGLIONS CLINICAL CHARACTERISTICS: Arise on or within extensor tendons, patients complain of tenderness, aching, snapping. Usually occur over metacarpals, move with finger motion. DDX: DWG, bossing, tenosynovitis. OPERATIVE TECHNIQUE: Transverse incision, dissect ganglion off tendon with all synovial tissue. MISCELLANEOUS LOCATIONS FIRST EXTENSOR COMPARTMENT (DORSAL RETINACULAR) GANGLION: Ganglion on sheath/pulley of 1st DC. RX: Release and excise. CARPAL TUNNEL: Ganglion can arise from volar carpus. Explore tunnel during all carpal tunnel releases to rule out extrinsic masses, including ganglions. GUYON‘S CANAL: Ganglion arises from joints around hamate, can compress ulnar nerve and cause motor and/or sensory loss. Early excision is imperative and avoids permanent injury to nerve. INTRAOSSEOUS GANGLIONS: Rare, usually incidental x-ray finding. Increasingly recognized as source of wrist pain. Exclude all other sources of pain before surgery: curettage and bone grafting, explore joint. CHAPTER 68 – SKIN TUMORS (Fleegler) Ominous c/o: Continuous growth, ulceration, deformity, odor, enlargement, firmness.

ANATOMY: Dermis lies between epidermis and SQ fat. In dermis, hair follicles, sebaceous glands (dorsum), and eccrine sweat glands (palmar) BENIGN TUMORS CUTANEOUS HORNS CYSTS – Inclusion cyst – excision biopsy frequently needed. GLOMUS TUMOR -SXMS: severe pain, cold sensitivity, tender -PE: may be red-blue, nail plate ridging -X-RAY: bony defect in distal phalanx -RX: Remove nail plate and completely excise tumor. Recurrence uncommon. If unsure, may need exploration/excision. DERMATOFIBROMA (CUTANEOUS FIBROUS HISTIOCYTOMA) -Small, round, well-circumscribed, firm, benign skin lesion. Color varies: skin tone, red, brown, black -RX: Excisional biopsy. Recurrence rare. KERATOACANTHOMA (KA) -Commonly on sun-exposed areas of mid-older patients -PE: Elevated, papular growth, dome/crater. Presentations vary. -PATHOLOGY: Must evaluate entire tumor. Sometimes difficult to differentiate KA from squamous cell carcinoma. -RX: Wide excision, reconstruct with local flaps/skin grafts. Currette/marginal excision of subungual lesion if pathology unequivocally KA ACTINIC KERATOSES (AK) -Secondary to sun exposure, AK‘s are pre-malignant (squamous / basal cell CA) -PE: Thick, hyperkeratotic scaly lesions -RX: Excision or destruction with 5-fluorouracil cream SWEAT GLAND TUMORS (Benign ones may undergo malignant degeneration) ECCRINE POROMA – Benign. Middle age to older patients, asymptomatic, small/soft mass. RX: Wide excision. CHONDROID SYRINGOMA – Can be large ECCRINE SPIRADENOMA – Single or multiple MELANOCYTIC NEVI = moles = nevi -Collections of melanocytes -Congenital vs. acquired -Benign: well circumscribed, regular border, symmetric, uniform color -Worrisome: Loss of above benign features, ulceration, change

MALIGNANT SKIN TUMORS (SCC = squamous cell carcinoma, BCC = basal cell carcinoma, MM = malignant melanoma -Some changes are subtle and delay RX (i.e. appear like recurrent paronychial infection) -Non-melanoma skin cancer is most common cancer in whites in U.S. (SCC>BCC) -RX principle: wide resection, mount on diagram (to know where to resect more if needed), irrigate/hemostasis, change drapes, instruments, gowns/gloves, re-irrigate and cover DERMATOFIBROSARCOMA PROTUBERANS -Intermediate malignancy. Tends to recur locally; may metastasize to lymph nods and lungs. -PE: Slowly enlargening raised mass -RX: Wide surgical resection MALIGNANT FIBROHISTIOCYTIC (MFH) TUMORS -Some involve skin, include angiomatoid MFH, atypical fibroxanthoma -PE: Nodule or ulcerated area -RX: Wide surgical resection; risk of recurrence and metastasis BASAL CELL CARCINOMA (BCC) -Secondary to sun, often multiple, recur -PE: pink/red, ulcer, ―pearly‖ border -RX: wide resection -OTHER RX: MOH‘s, radiation SQUAMOUS CELL CARCINOMA (SCC) -Secondary to sun, irradiation, HPV, chemicals, burns (=Marjolin‘s ulcer) -PE: papular, ulcerated, erythematous - >2cm: 2x recurrence & 3x mets -5-year survival with mets = 25% -RX: wide resection (2cm margins) MERKEL‘S CELL CARCINOMA -Merkel‘s cell = pressure receptor -These rare tumors are malignant with high met rate -HX & PE: Rapidly growing, painless, firm, non-tender, blue-red, intracutaneous nodule 0.5-5cm -RX: Wide resection and lymphadenectomy MALIGNANT SWEAT GLAND TUMORS -Include clear cell carcinoma, aggressive digital papillary adenocarcinoma (=ADPA), eccrine adenocarcinoma -ADPA: Palmar digits, older patients, ulcerate. RX: wide excision +/- lymph node dissection, +/radio/chemo RX.

MALIGNANT MELANOMA -Etiology: sun, inherited -TYPES OF MELANOMA: -LENTIGO MALIGNA = Melanotic freckle of Hutchinson. Small, flat, tan/brown/black/pink, irregular borders. Changes color and grows slowly. Histologically preinvasive. -LENTIGO MALIGNA MELANOMA – Invasive form of above. -SUPERFICIAL SPREADING MELANOMA – Most common form. Irregular border and surface. Colors vary (tan, brown, gray, black, red, white, blue) -NODULAR MELANOMA – Nodular/plaque/polyp. Rapid onset and vertically growing; mets early. -ACRAL-LENTIGINOUS MELANOMA – In palms and nailbed. Colors vary. Difficult diagnosis; can look like subungual hematoma, infection, melanonychia striata (benign peigmented streaks), eponychial staining. Biopsy if not sure. RX: Ablate digit. Consider limited amputation if proximal margins are negative and good patient f/u. MELANOMA CLASSIFICATION AND STAGING -Clark‘s depth of invasion / Breslow‘s measurements -Clark I – epidermis, II – to papillary dermis, III – fills papillary dermis, IV – invades reticular dermis, V – into SQ fat. BIOPSY -Complete excisional bx preferred -If large, may perform incisional bx RX -Wide resection with 2 cm margin (1 cm if < 1mm thick) -Regional lymphadenectomy is controversial MULTIPLE PRIMARY MELANOMAS – 5% MM patients with multiple lesions. Therefore all MM patients need at least Q6 month (Q3 if familial) f/u KAPOSI’S SARCOMA – Variable presentation. Blue-red/brown plaques/nodules. Can look like chronic paronychial infection. CHAPTER 69 – PRINCIPLES OF TUMORS (Edward Athanasian) CLASSIFICATION AND STAGING OF TUMORS HISTOLOGIC GRADE: G0 = Benign G1 = Low grade. Few cells, much stroma, little necrosis, mature cells, < 5 mitoses / HPF (high power field) G2 = High grade. Many cells, little stroma, much necrosis, immature cells, > 10 mitoses / HPF (high power field)

SURGICAL STAGING: BENIGN, STAGING STAGE I, LATENT: Do not merit treatment; they usually heal spontaneously and/or remain unchanged STAGE II, ACTIVE: Grow within a limited zone and are contained by natural barriers; if surgery is required, these tumors are most often controlled by intralesional or marginal excision STAGE III, LOCALLY AGGRESSIVE: May both grow and spread beyond natural barriers; excision requires wide surgical margin or en bloc resection for local cure MALIGNANT, STAGING: (from Enneking, accepted by the Musculoskeletal Tumor SocietyMSTS) STAGE IA = Low Grade (G1), Intracompartmental (T1), No Metastasis STAGE IB = Low Grade (G1), Extracompartmental (T2), No Metastasis STAGE IIA = High Grade (G2), Intracompartmental (T1), No Metastasis STAGE IIB = High Grade (G2), Extracompartmental (T2), No Metastasis STAGE III = Any Grade, Any T, Positive Metastasis METASTASES – Primary musculoskeletal neoplasms do not commonly spread to regional lymph nodes (<5%). If positive nodes, think to add carcinoma and melanoma to DDX. Nodal involvement more prevalent with rhabdomyosarcoma, epithelioid sarcoma, clear cell sarcoma, synovial sarcoma. EVALUATION PROTOCOL: H&P LABORATORY STUDIES: Calcium, Phosphorus, BUN / Creatinine (evaluate for metabolic bone disease). Alkaline Phosphatase and Lactase Dehydrogenase (elevated in some malignancies). SPEP / UPEP (for multiple myeloma). CBC/ ESR abnormal in many neoplasms. U/A may detect occult renal cell carcinoma. RF / ANA to R/O RA causing upper extremity swelling. DIAGNOSTIC IMAGING: PLAIN X-RAYS-CXR before biopsy of suspected malignancy; CTevaluate extent of bone involvement, chest CT for staging of malignant tumor after biopsy; BONE SCAN-detection of skip lesions and metastases; MRI-evaluates soft tissue extension and relation to NV structures. Majority of soft tissue tumors have low T1 signal and high T2 signal. Some pathology (hematoma, lipoma, liposarcoma, hemorrhage into tumor zone) have high T1 signal; ULTRASOUND-distinguishes cystic vs. solid masses BIOPSY NEEDLE BIOPSY – Extremely limited role in hand and upper extremity OPEN BIOPSY – Complex. Institution and surgeon must be prepared to treat fully; if cannot, then refer before biopsy. Use tourniquet; elevate arm 3 minutes before inflation (do not use Esmarch-this may dislodge tumor cells). Do not use Bier block. Need frozen section to determine if tissue is adequate. Culture all. Biopsy tract will be contaminated in the case of malignancy and will have to excised later, so use longitudinal incision that does not contaminate other compartments.

INCISIONAL BIOPSY – Most usual method. Direct approach through muscle and other tissue that overlie mass; minimize spreading and retraction. Suture tag for orientation. Complete hemostasis to avoid hematoma. EXCISIONAL BIOPSY – Complete removal of lesion with margin of normal tissue. Should be reserved for very small lesions (diameter less than 1-2 cm) DEFINITIVE TREATMENT GENERAL PLAN OF TUMOR EXCISION BENIGN TUMORS – Benign, nonaggressive neoplasms may be removed by marginal or intralesional excision. MALIGNANT TUMORS – Function secondary to survival. Radiation and chemotherapy may decrease size of necessary resection. According to MSTS criteria, compartmental and radical resections do not apply to the hand / upper extremity

SURGICAL PROCEDURES FOR EXTREMITY SARCOMAS (Enneking) INTRALESIONAL = Within tumor (debulking, piecemeal excision/curretage) MARGINAL = Within reactive zone WIDE = Through normal tissue, but within compartment RADICAL = En bloc resection of entire compartment PRINCIPLES FOR SPECIFIC SITES DISTAL PHALANX – Malignant soft tissue tumors of the distal phalanx often involve skin and bone. Resect with a cuff of normal tissue (determined with frozen section). Level depends on tumor extent (DIP disarticulation, trans-middle phalanx, etc. proximally) MIDDLE PHALANX – Needs at least 2-3 cm margin of normal tissue. Functional and aesthetic considerations strongly recommend ray resection. FIRST METACARPAL – If intracompartmental, treat with osseous excision and autogenous (fibular or iliac; through second, separate surgical setup to avoid cross contamination) or metatarsal or metacarpal allograft. If broken through bone, need ray resection, possibly with parts of 2nd metacarpal. Consider pollicization. FINGER METACARPALS – Ray resection usually best for lesions of 2nd through 5th metacarpals; consider ray transposition. Aggressive tumors invading soft tissue may need resection of adjacent rays. Tumors in palm or dorsum may need partial hand amputations or proximal. WRIST AND DISTAL FOREARM – Malignancies of the palmar hand and volar wrist and volar forearm usually require amputation (invasion into neurovascular structures and tendons). Tumors of the dorsum may allow preservation of the the hand if staging studies show no extension into the palm. If tumor does not specifically involve NV structures, it may be possible to save a portion of the hand and wrist. Intracompartmental lesions of the distal radius or ulna may be treated with wide excision of the bone and arthrodesis or autograft. CHAPTER 70 – TUMORS (Edward Athanasian)

BENIGN SOFT TISSUE LESIONS GANGLIONS AND MUCOUS CYSTS – See Chapter 67 EPIDERMAL INCLUSION CYSTS – Thought to be from traumatic implantation of epithelial cells into the underlying soft tissue or bone. Cells grow over months to years. Patients present with slowly growing mass usually of digit tip. Usually well circumscribed, firm, slightly movable, painless; although can be erythematous and painful. If involves bone, may be lytic, mimicking malignancy or infection. RX: marginal excision, or curettage and bone graft. Recurrence uncommon; malignant transformation not reported. FOREIGN BODY LESIONS – In response to implanted foreign material; may be impossible to distinguish from inclusion cyst or neoplasm. RX: Excisional biopsy. LIPOMAS – Most commonly subcutaneous or intramuscular, but also in tendon sheaths, carpal tunnel, Guyon‘s canal, deep palmar space. May grow slowly. May compress nerves. MRI: fat signal. If sure lipoma, excisional biopsy. If not sure, incisional biopsy first. Marginal excision generally curative for lipomas, although recurrence may be seen. LIPOFIBROMATOUS HAMARTOMAS – Unusual tumors of peripheral nerves most commonly of the median nerve when in UE. Present with slowly progressive swelling in distal forearm or palm, usually in childhood or adolescence, and nerve compression symptoms may be seen. Surgical exploration reveals fusiform swelling of nerve intimately associated with nerve fibers. Biopsy branch first; if diagnosis confirmed, then decompress without interfascicular dissection. If size requires excision, consider nerve grafting in children or immediate tendon transfers in adults. GIANT CELL TUMOR OF TENDON SHEATH (=PIGMENTED VILLONODULAR TENOSNOVITIS=FIBROUS XANTHOMA=LOCALIZED NODULAR SYNOVITIS) – A benign soft tissue tumor-2nd most common in hand (after ganglions). GCTTS not good name because they do not uniformly contain giant cells and not necessary associated with tendon sheath. Usually occur on volar surface of fingers or hand, although dorsal not uncommon. Propensity for radial 3 digits and DIP. Clinically, firm, nodular, nontender, slow growing. May pressure into bone, but bone invasion not typical. RX: marginal excision, but recurrence 5-50%. Malignant transformation not reported, but malignant form of GCTTS has been described. SCHWANNOMAS (NEURILEMOMA) – Most common benign nerve tumor in UE. Arise from Schwann cell and is slow growing, well-circumscribed, eccentric lesion of peripheral nerve. Most commonly on flexor surface of forearm or hand in 4-6th decades. Usually painless mass, less commonly neurologic deficit. May have positive Tinel. Usually mobile transversely, not longitudinally. Frequently misdiagnosed as ganglion. MRI may help, but may not be able to distinguish between neurofibroma or malignant peripheral nerve sheath tumor. At surgery, schwannomas are easily dissected free (shelled out) and neurologic symptoms improved. Post op neurologic deficit 4%. Recurrence uncommon. Rare malignant transformation. NEUROFIBROMAS – Benign nerve tumors arising from fasciculi; more difficult to excise than schwannomas. Multiple form (neurofibromatosis=von Recklinghausen‘s disease) more common than solitary form. Symptoms and exam similar to schwannoma. Higher risk of neurologic deficit after surgery. Surgical treatment for neurofibromatosis should only be if growing or producing symptoms. Risk of malignant degeneration. GRANULAR CELL TUMORS (=GRANULAR CELL MYOBLASTOMAS) – Rare in forearm and hand. Appears to arise from neural elements. Usually present with painless mass. Malignant

form difficult to distinguish from benign. Malignant is higly aggressive and needs wide excision and possible systemic treatment. FIBROMATOSES DIGITAL FIBROMA OF INFANCY – Benign but very aggressive fibrous lesion seen almost exclusively in fingers or toes, with >80% before 1 year old. Usually in IP region of fingers, small, dome shaped, skin colored, and painless. No firm RX guidelines, but APM: Observation until spontaneous resolution or deformity or contracture, which would require wide excision and skin graft. High risk of local recurrence. JUVENILE APONEUROTIC FIBROMA – Benign, aggressive fibrous lesion most commonly in palm. Small, painless mass, often associated with tendon or NV structures; difficult to distinguish from fibrosarcoma. RX: wide excision, but recurrence > 50%. Recurrent lesions may be observed if no functional impairment and diagnosis not in question. NODULAR FASCIITIS (=pseudosarcomatous fasciitis=subcutaneous pseudosarcomatous fasciitis=infiltrative fasciitis) – Uncommon, poorly understood, may mimic sarcoma. Usually on volar surface of forearm and rarely in hand. Present with rapidly growing nodule, may be tender. Histologically may mimic fibrosarcoma or myxoid liposarcoma, which has led to overtreatment. MALIGNANT SOFT TISSUE LESIONS SOFT TISSUE SARCOMAS – Relatively rare in hand and forearm. 750 new cases / year in U.S. Majority have common mesodermal origin. Most common histologic subtypes are epithelioid sarcoma, synovial sarcoma, and malignant fibrous histiocytoma. More importantly to behavior is histologic grade, not subtype. CLINICAL PICTURE – Usually painless (but may be painful) mass present for long time, possibly with recent growth. May be misdiagnosed as infection, ganglion, or lipoma. BIOPSY – should be done if symptomatic, enlargening, or not readily diagnosed by physical exam (see Chapter 69). SURGERY – (Similar principles despite type of tumor) Goal is complete removal of tumor with cuff of normal tissue (2-3 cm). If negative margins cannot be achieved, then amputation should be strongly considered. Brachytherapy or external beam radiation should follow wide excision of large (>5 cm) high-grade lesion. If large low-grade, then follow with external beam radiation. Small lesions of either grade may not need radiation, but this has not been conclusively answered in hand. Role of chemotherapy is still under investigation: Pre- and post-op chemotherapy protocols in conjuction with medical oncologist. Consider resection of lung nodules. EPITHELIOID SARCOMA – Most common soft tissue sarcoma in the forearm and hand. Notorious for innocuous appearance, frequent misdiagnosis, propensity of local recurrence, and regional lymph node metastasis (42% vs 5% in other sarcomas). Commonly present as painless nodule on volar digit or palm, may ulcerate, mimicking infection. Spreads along tendons, lymphatics, fascial planes. RX: Aggressive surgery with wide excision, radical resection, or amputation; lymph node excision may be life saving. Possible radiation / chemotherapy (get team involved). SYNOVIAL SARCOMA – Most commonly in region of carpus and rarely in fingers. Painless mass in dorsum hand or palm, often present for many years, and can lead to false impression of benign nature. Arises near joints, tendons, or bursae. Soft tissue calcification in 20-30%. Lymph node mets in 25%. RX: Follow principles. LIPOSARCOMA – Rare in hand. May resemble lipomas, but more often are painful and grow rapidly. Approach lipomas as potentially malignant. RX: Follow principles FIBROSARCOMA – 30% in UE, but rare in hand. RX: Follow principles

DERMATOFIBROSARCOMA PROTUBERANS – Uncommon low-grade malignancy in forearm and rarely hand. Arises in dermis and most often presents as painless violet-red plaque or nodule that may be present for several years; spreads horizontally in dermis, goes deep, ulcerates. RX: Needs 3cm margins-still with 12% local recurrence. MALIGNANT FIBROUS HISTIOCYTOMA – 19% in UE, many in forearm; may arise from soft tissue or bone. Bone lesions are lytic and may arise for Paget‘s or bone infarct. RX: Follow principles MALIGNANT PERIPHERAL NERVE SHEATH TUMOR (=NEUROFIBROSARCOMA=MALIGNANT SCHWANNOMA) – 30% occur in UE, with 50% in neurofibromatosis. Not sensitive to radiation or chemotherapy. RX: Wide excision or amputation RHABDOMYOSARCOMA – Round cell tumor, most commonly in childhood, rare in hand. RX: Limb-sparing wide excision and chemotherapy and radiation. Also lymph node evaluation. LEIOMYOSARCOMA – Most commonly in viscera, rare in hand. From smooth muscle— vessels. RX: Wide excision and adjuvant RX. CLEAR CELL SARCOMA – uncommon, associated with tendon and aponeuroses. RX: follow principles. BENIGN BONE TUMORS ENCHONDROMA – Most common primary bone tumor (90%) in hand. Monostotic lesions, between 10-40 y.o. Proximal phalanx most common, then metacarpal and middle phalanx; carpus rare. Present incidentally, or with swelling, may be painless, or after pathologic fracture. Radiographs: well-defined lytic lesion, may be lobulated, matrix calcification. RX: Small asymptomatic lesion-observe. Large or symptomatic-biopsy and currettage. Pathologic fracture may be treated acutely or after healing. SURGERY (APM): Lateral approach to phalangeal lesions (not dorsally) to minimize scarring and contamination. Initial biopsy through limited exposure and diagnosis confirmed on frozen section before proceeding with wider exposure. Fill thoroughly curetted cavity with freeze-dried irradiated allograft mixed with patient‘s bone marrow. Does not use autograft in treating any bone tumor in hand, to avoid risk of cross contamination of tumor cells. Malignant degeneration rare. MULTIPLE ENCHONDROMATOSIS (OLLIER‘S DISEASE) – uncommon, nonhereditary. Usually unilateral. 30% maliganant transformation; growth, radiographic progression, or pain should raise question. MAFFUCI‘S SYNDROME – Extremely rare; usually affects hands. Similar to Ollier‘s, but also with multiple hemangiomas which may show as phleboliths on x-ray. High risk of both bone and soft tissue sarcomas. PERIOSTEAL CHONDROMA – Uncommon, most commmonly male in 2-3rd decade. Most commonly at metaphyseal-diaphyseal junction of phalanges. Radiographs: external cortical erosion by a lytic unilobular lesion with a faint overlying calcified rim. RX: Marginal excision with overlying periosteum. Recurrence < 4% OSTEOCHONDROMA – Osseous growth with hyaline cartilage cap, most commonly at distal proximal phalanx. RX: If asymptomatic, then observe. Marginally excise if deformity, pain, dysfunction. High recurrence rate. Malignant transformation not reported in hand (unlike general skeleton)

SUBUNGUAL EXOSTOSIS – May be confused with osteochondroma. Has fibrocartilage cap, not one of hyaline cartilage. RX: nail removal and excision of exostosis. CHONDROMYXOID FIBROMA – Rare. Long h/o mild pain/swelling. Radiographs: lystic lesion in metaphysis, cortical expansion, sclerotic rim. RX: currettage and bone graft OSTEOID OSTEOMA – 5-15% in hand/wrist, most commonly in proximal phalanx and carpus. Radiographs most commonly lytic lesion (<1 cm) , not classic nidus. Location: cortical, medullary, or subperiosteal. CT and bone scan may help. Present typically in 2-3rd decade with deep, dull constant ache relieved with NSAIDs. May be painless with primary c/o swelling. EXAM: tender, swelling. RX: curettage or en bloc excision. OSTEOBLASTOMA – Usually larger than 2 cm. Differentiate from osteoid osteoma by size and location (medullary). Local recurrence 20-30% with curettage and bone graft. If recur or locally destructive, may require marginal or wide excision. UNICAMERAL BONE CYST – Rare in hand/forearm. Usually asymptomatic until pathologic fracture. Radiographs: lytic metaphyseal lesion with well defined borders. RX (APM): biopsy, curettage, bone graft with allogaft following frozen section diagnosis. ANEURYSMAL BONE CYST – Expansile deformity and thin bone rim. RX (APM): Biopsy, frozen section, curettage, cryosurgery, bone grafting. (Cryosurgery reduces recurrence). If recurs, may perform second curettage and cryosurgery if sufficient bone stock. Or wide excision and reconstruction, possibly with diaphyseal fibula bone graft. GIANT CELL TUMOR OF BONE – Although histologically benign, they should be treated like low grade malignancies since they are locally aggressive and can metastasize. Most commonly in 4th decade. Most common in metacarpals and phalanges. May be multicentric. Present with pain and swelling or pathologic fracture. Radiographs: lytic lesion with indistinct borders, no matrix. May have cortical expansion, destruction, soft tissue extension. RX (APM): After diagnosis, stage with bone scan, CXR and chest CT. SURGERY: Biopsy, frozen section. If lesion does not perforate bone and adequate bone stock exists: consider curettage, burring, cryosurgery, cementation. For lesions that perforate the cortex: in phalanges or metacarpals: wide en bloc excision or amputation. Lesions in proximal carpal row: proximal row carpectomy. Distal carpal row lesion: wide excision and limited carpal fusion. Distal radius: wide excision and reconstruction with fibula graft or distal radius allograft. Chemotherapy not effective. Radiation effective, but associated with 8.7% malignant transformation. MALIGNANT BONE TUMORS CHONDROSARCOMA – Most common primary malignant bone tumor in hand. May also develop from pre-existent encondroma or osteochondroma. Most commonly over 60 y.o. Proximal phalanges and metacarpal most common. Presents as slowly growing, firm, often painful mass. Radiographs: lytic, stippled calcification, poorly defined border; may have cortical expansion, perforation, extension into soft tissue. Metastasis 10%. RX: Well planned incisional biopsy, frozen section, wide en bloc excision or digit or ray amputation. No role for radiation. Chemotherapy not effective in majority. Follow for both local and systemic recurrence-may show years later. OSTEOGENIC SARCOMA – Rare in hand. 4-6th decades, often form pre-existent lesion. Present with rapidly enlargening mass that is firm and painful. Radiographs: expansile, sclerotic

lesion with mix of lysis and new bone formation, soft tissue extension. Most commonly in proximal phalanges and metacarpals. RX: Well planned incisional biopsy. Immediate neoadjuvant chemotherapy (decreases tumor size-may facilitate wide en bloc excision – vs. amputation and improve quality of margins), followed by adjuvant chemotherapy and prolonged surveillance for recurrence. EWING‘S SARCOMA – Rare in hand. Most commonly in 1-2nd decade. Present with pain, swelling, and erythema, fever, elevated WBC & ESR. May mimic infection. Radiographs: large lytic, destructive, expansile lesion with soft tissue component. MRI very useful. RX: Incisional biopsy, cytogenetic analysis by pathologist. APM: immediate chemotherapy, then wide en bloc excision or amputation, followed by chemotherapy and possibly radiation. METASTATIC TUMORS – Metastasis to hand is uncommon. Usually preterminal event, with median survival 6 months. Present with pain, swelling, erythema. Misdiagnosis common (infection, osteomyelitis, felon, gout, RA, RSD, fracture). Radiographs: lytic destructive lesion, soft tissue extension. RX: biopsy and culture without delay. Once diagnosed, RX of pain relief and preservation of function. For digits and metacarpals, consider amputation and ray resection for local control. For carpus, consider curettage and packing with methylmethacrylate rather than amputation (considering terminal patient). Radiation may be considered.

VASCULAR TUMORS -Incidence of 2-6%, 4th in frequency after ganglions, giant cell tumors, and inclusion cysts -Diverse group of abnormalities VASCULAR ANOMALIES 2 MAJOR CATEGORIES -Vascular Malformations -Hemangiomas VASCULAR MALFORMATIONS CLASSIFICATION – 2 GROUPS LOW FLOW -Capillary Malformations -Venous Malformations -Lymphatic Malformations -Combination HIGH FLOW -Arteriovenous Malformations PATHOGENESIS -Vascular differentiation occurs between the 4th and 10th weeks of gestation -Failure to ―prune‖ communications between the arterial and venous systems

-Important clinical considerations: 1) size, 2) pain, 3) hemodynamic significance, 4) structural significance INCIDENCE -Rare -Upper extremity involved in 30-60% -Although present at birth, 50% are noticed before age 2; some not noticed until adulthood HISTORY (mainly in high flow lesions) -Common initial symptoms: pain, swelling, mass, heaviness, increased temperature, weakness PHYSICAL EXAM -Mass, pulsatile/thrill, bruit, skin discoloration, edema, decreased distal pulses, joint stiffness -Nicolandoni Sign: Fall in pulse rate with complete occlusion of malformation DIAGNOSTIC TESTS RADIOGRAPHS -Soft tissue mass -Pathognomonic phleboliths in 50% in Low Flow Malformations -Bony appositional resorption or hypertrophy often seen ARTERIOGRAM -Diffuse lesion -No parenchyma -High Flow: Enlarged, tortuous with arteriovenous shunting MRI/A -Anatomic and vascular flow information OTHER TESTS -DOPPLER -PULSE VOLUME RECORDING TREATMENT NONOPERATIVE TREAMENT -If low flow malformation and minimal symptoms, then compressive wrap/sleeve -If symptoms from distal ischemia, consider vasoactive medications: Calcium channel blockers, Alpha-adrenergic agonists -Selective embolization (NBCA: N-Butyl Cyanoacrylate adhesive or Polyvinyl Alcohol FoamIvalon) used to decrease flow to high-flow AVMs before surgical excision and/or amputation; reduces blood loss -Cryotherapy and radiation not effective OPERATIVE TREATMENT -Indicated if diminished function, neurologic compromise, significant increase in size, pain -Operative procedure usually not curative, since it is very difficult to perform complete excision

-Usually extensive and complex with multiple feeding and draining vessels. -Usually can only achieve subtotal resection, and has high rate of recurrence -Successful surgical excision is compromised by activation of quiescent AV channels, creation of distal ischemia, involvement of muscle and bone, and stimulation of angiogenesis DISSEMINATED INTRAVASCULAR COAGULATION -Serious possible operative complication -Obtain preoperative coagulation studies -Meticulous intraoperative hemostasis important MENDEL & LOUIS, JHS, 1997 -17 patients with upper extremity vascular malformations, average follow-up 12 years -Diffuse lesions ―defied total surgical removal‖ -4 required amputations: 1 primary digital, 2 digital after recurrences, 1 above elbow after high output congestive heart failure -Recurrence and persistence in 12/17 (71%) -Many required repeat surgery, one patient required 10 repeat excisions SPECIFIC TYPES OF MALFORMATIONS CAPILLARY MALFORMATIONS -Dilated capillaries and venules in the dermis -Known as ―port wine stains‖ or Nevus flammeus -Present at birth as flat, pink, circumscribed lesions. Grow in proportion with child; dark red/purple in adulthood. -RX: Laser can destroy abnormal vessels in the dermis VENOUS MALFORMATIONS -Most common in low flow group -―Cavernous hemangioma‖ was old term LYMPHATIC MALFORMATIONS -Uncommon -Old terms: cystic hygroma, lymphangioma ARTERIOVENOUS MALFORMATIONS -Can ―steal‖ from distal vessels ARTERIAL ANEURYSM & PSEUDOANEURYSM PSEUDOANEURYSM -Occur after injury of vessel wall and subsequent hemorrhage and extravasation. -Lumen of the false vessel has no endothelial layer. -Sac-like appearance -Caused by sharp or blunt trauma

ANEURYSM -Lumen has endothelial layer. -Fusiform shape -Etiology: repetitive trauma, arteriosclerotic, congenital TREATMENT -Given natural history of possible embolization and distal ischemia, surgical treatment of true and false aneurysms is warranted

HEMANGIOMA GROWTH CYCLE -True tumors with a characteristic growth cycle of 3 phases - 30% seen at birth, but 70-90% visible by 4 weeks -1st PHASE: 10-12 months of rapid growth, changes from red-purple lesion to large, bright red or bright blue lesion -2nd PHASE: Grows at same rate as child; color fades to dull red or purple -3rd PHASE: Involutional: shrinks and fades. By 5 years, 50% regressed; by 7 years, 70% involuted -Some do not involute; usually capillary or cavernous -Noninvoluting capillary hemangiomas are usually ―port-wine stain‖ or nevus flammeus -Noninvoluting cavernous hemangiomas usually have arteriovenous flow INCIDENCE -Females: Males 3:1 DIAGNOSIS -History of growth cycle RADIOGRAPHS -Soft tissue shadow -Calcifications may be present -Usually does not cause ―mass effect‖ on bone -Bony hypertrophy rare ANGIOGRAPHY -Well-circumscribed lobular parenchyma

MANAGEMENT -Usually nonoperative, since the majority involute by 7 years -May need to treat associated complications of bleeding, ulceration, infection BLEEDING -Particularly in neonatal stage -RX: compression dressing, elevation, blood products. -KASABACH-MERRITT SYNDROME: Rare complication of diffuse coagulopathy secondary to platelet trapping within the hemangioma. RX: Platelets, fresh frozen plasma, pressure. ULCERATION AND SUPERFICIAL INFECTION -Dressing changes and antibiotics OPERATIVE TREATMENT INDICATIONS -Noninvoluting lesion where diagnosis is a question -Complications of nonoperative treatment occurs SURGICAL TECHNIQUE -Ligation of feeders and complete excision if possible PROGNOSIS -Higher recurrence if diffuse

GLOMUS TUMORS -Benign vascular tumors containing all cells of normal glomus apparatus NORMAL GLOMUS -Lies in the reticular layer of the dermis as an AV anastomosis in the dermis and functions as a thermoregulatory control mechanism -Apparatus consists of: 1) afferent vessel, 2) Sucquet-Hoyer canal surrounded by large polygonal cells, 3) multiple shunts in the glaborous skin of the hand and beneath the nail beds DIAGNOSIS HISTORY CLASSIC TRIAD -Cold Sensitivity -Paroxysmal Pain -Pinpoint Pain -75% in hand, 65% subungual PHYSICAL EXAM -Unfortunately, only 50% have objective evidence: blue discoloration under nailbed, nail ridges

-Severe pain with light touch or cold exposure (immerse in ice water or spray with ethyl chloride) MRI -Dark on T1, bright on T2 CLASSIFICATION -Solitary lesion -Multiple painful lesions -Multiple painless lesions (25% have multiple lesions) TREATMENT -If symptomatic, then surgically excise -20% recurrence SURGICAL TECHNIQUE -Remove nail. Longitudinal incision on sterile matrix over lesion, and excise. Explore to not leave multiple lesions. If lesion proximal near germinal matrix, then approach dorsolaterally at the junction of glaborous skin.


VASOSPASTIC DISEASE -Inappropriate cold sensitivity, in 5-10% population, 20-30% of premenopausal women Raynaud’s Disease (primary, without underlying cause). Triphasic (white, blue, red), bilateral hands, absence of ulcers or gangrene, usually female. Raynaud’s Phenomenon (secondary, usually underlying cause, usually collagen vascular disorder, ie scleroderma). Triphasic, unilateral, ulcers or gangrene.

*non-healing ulcers or gangrene with unilateral Raynaud’s symptoms is presumptive thrombosis or embolism -Physical exam: pulses, ulcers/gangrene, Allen test at wrist and digits -Lab work-up: hematologic and collagen vascular abnormalities (rheumatology consult) -Other work-up: -Functional evaluation: Digital plethysmography and temperature measurements with and without stressors -Structural evaluation: arteriography is gold standard (indications: unilateral Raynaud‘s phenomenon, ulcer/gangrene, suspected occlusion/embolism). Need regional anesthetic block (axillary block) during arteriogram to differentiate vasospasm vs structural defect , Segmental Arterial Pressures (Digital Brachial Index DBI of < 0.7 suggests stenosis or occlusion)

TREATMENT NON-OPERATIVE -Smoking cessation (most important) -Avoid cold / protective garments -Biofeedback -Pharmacologic agents (calcium channel blockers: nifedipine 10-30mg PO TID or long acting form 30-60mg QD, tricyclic antidepressants (TCAs): amitriptyline (Elavil) 25-75m po QHS, serotonin reuptake inhibitors (SSRIs): fluoxetine (Prozac), sertraline (Zoloft), paroxetine (Paxil). OPERATIVE PROCEDURES TO ALTER SYMPATHETIC TONE PALMAR/WRIST SYMPATHECTOMY -Indication: refractory to non-operative (including pharmacologic agents) treatment, nonhealing ulcer, gangrene -Preoperative evaluation: arteriogram, assess functional control SURGICAL TECHNIQUE OF PALMAR/WRIST SYMPATHECTOMY (Koman Technique) -Expose radial and ulnar arteries by 2 parallel incisions proximal to wrist , connections between arteries and nerves transected over 3 cm length, under microscope adventitia dissected off radial and ulnar arteries for 2 cm length. Expose superficial arch and 3 common volar digital arteries through transverse palmar incision and transaction artery/nerve connections and strip adventitia. Palmar incision for thumb and also radial artery at snuff box. SURGICAL TECHNIQUE OF DIGITAL SYMPATHECTOMY (Flatt and Wilgis Technique) -Digital arteries and nerves exposed through Bruner incisions from PIP to distal palmar crease, artery/nerve connections transected and strip adventitia. ARTERIAL RECONSTRUCTION

-If circulation inadequate and DBI < 0.7, vascular reconstruction is indicated, if possible (The presence of reconstructable distal arterial channels is necessary and does not exist in many diseased extremities) -Peripheral sympathectomy alone is salvage procedure SURGICAL TECHNIQUE ARTERIAL RECONSTRUCTION -Excised thrombosed segment and end-to-end repair under no tension vs reverse vein graft

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