Atlas of Hand Surgery Sigurd Pechlaner, M.D. University Cnc of Trauma Surgery Department of Hand Sutery Leopold rans Univesity Innabrck, Aust Fridun Kerschbaumer, M.D. Profesor, Orthopedic University Cini Beporament of Rheumatic Orthopedics Joann Walgang Goethe University Franti, Germany ‘Anatomy by Sepp Poisel, M.D. Profi iste of Anatomy leopla Frazens Universi Tonebrck, Austria Iustratios: ood Grater 1459 austatons ye Thieme Stuttgart - New York 2000 Heribert Hussl, M.D. Professor, ln of Paste fand Reconstructive Surgery topo Franzen University Innsbruck, AstaPreface ‘The many queries the authors received about techniques they used and recommended in hand surgery provided the mothation for eeating this las of Hand Surgery This atlas provides am sight nt the author's personal ‘ews and into sug techniques the authors practice, ‘ich have evalved in many years of cinical experienc, Ds result, many af the teehniques presented ere are deviations from er further developments of wel-knoven triginal techniques, Ths the reasoning behind the Suthor's decison to deliberately focus only on selected {echniques without any claim to compreteasive eat ‘ment ofthe subject The als ts atmed primarily at prac- ficing orthopedic surgeons wo deal withthe specific problems of hand surgery. However, also allows the beginner to obtain an overview of various proven surgi- cal procedures and suggestions for the treatment of Specie injuries and disorders. ‘The clinieal authors specaliies—trauma surgery plastic 2nd reconstructive surgery, orthopedi¢s, and theumati ‘Srgery-emphasize that hand surgery has become a dlscpline nits own ght within varous specaltes The tstensive knowledge demanded of today's hand su eons requires specialization above and beyond the in- fevasciptnary approach. The Als of Hand surgery is organized acording to prac- thei considerations, Preceding the main section of the book an introductory anatomic chapter tat presents sil-major detalls. ll subsequent portions of the book fefer Dac to tis chapter We would like oak this op- Dorunity to express our special thanks to Pro. r. Sepp Poise for successfully bridging the gap between ana ‘omic terminology and cincal usage ‘Nehapleron skin and saft-ussu injuries introduces the main clineal section, This followed bya section ox i= ‘rosurpcal techniques. The next chapters handle the treatment of compression neuropathies ad tendon transfers, fllowed by chapters on tendon injures dist ations and fractures A Selection of procedures fr the Suigleal managermeat of selected seumatic disorders nd Dupuytrens contracture rounds ou the volume, i= tially a chapter on surgical management of infections ‘iseases war planned, but this Rad tobe elisnated for Several reasons I wl be included ina revised edition ‘particular advantage ofthe Aas of Hand Surery 35 3 ‘dy tool isthe consistent outline ase to present the = tividual procedures an techniques. Indieation surgical technique, and postoperativemanagement are primarily presented in illustrations and legends orin concise de- crite text passages Despite ths restrictive approach ‘hose by the authors inthe terest of ensuring a jd ‘ous presentation of information, every effort has been made fo malnainthe character of readable atlas suhose stations provid immediate access to dale infor. Imation in reacily comprehensibe form. Some practicing ‘rgeons may find feuusual tht the chapters area ange stitly by region. However, the compreliensive fable of conten also permits Une more conventional ap- proach of lecating information by syndrome. Fhe scope ofthis foreword doesnot pera us to thank ‘AVof our colleagues whose advice ana assistance have Sccompanied the cretion ofthe Aas of Hand Surgery, Sind we ak their understanding However we woul ike totake this oppereunity to offer thanks to our teachers in fn appropriate manner. Recogniing the signs of the times they introdiced us os ascinating ateaof work fand paved the way for us. Among them are Professors Hane Andetl, Rudo Bauer, Eri! Beck, Walter Blauth, Jorg Bahle, eter Suei-Grameko, Ulich Lane, Lennart MManperet Hanno Miles, Wayne A. Morrison, Henry Nisse Berard O'ren, Gnther Pailadtphy, Werner Patee, Reinhard V, Put, Otto Russe, Gustav Sause mt Searizes, Walter Vogl and Paul Wifingseder. Georg Thieme Verlag Kindly supervised the work, Weare especialy grateful that it was pssbleto presente atlas Inthielaborate ection, The vivid drawings are the work (of Mr Jakob Gratzer, who created them with great per Sonalintiatve, workingtromoperatingroomanddissec- tion foom subjects. The authors extend ther special thanks to Ms, Renate Put, who showed enormous com mitment, exceptional attention te deta and clinical pprecationinbinging te existing material inoitscu tent ll frm nthe ial phases a the book. ‘The authors wish thatthe Alas of Hand Stogery wil fegeh 2 broad readership and they hope inthis manner {ohave made contribution to more enlightened teat- ‘nent ofthe "hand patient” The authors view their atlas SE topic for discussion among thelr ealeagues and ‘would be happy to ear any responses Innsbruck and Frankfurt Fall 1999 Sigur Pechaner Herbert tus Fridun Kerschbaumer vContents ” 20 a 2 2 24 26 2% 1_ Systematic and Topographic Anatomy ‘Systematic Anatomy 2 Dorsum and Pam ofthe Hand Passive Sructres, 2 long inger Steal system 2 _ Thumb Ligaments 5 Toposraty ofthe Nerves ofthe Arm sctive Strutares 9 "Median Nerve Utnar Nerve ‘Topographic Anatomy 14 Radial Nerve Regional Topography 14 cross-sectional Anatomy Forearm 4 2 Skin and Soft-Tissue injuries ‘Skin nesions 35 Rotated Advancement ap (Random Pattern Map. Free Skin Grats 36 —_igenilds Neurovascular san ap frm ‘Anatomy and Types of Skin Gratis 36 the Dorsal Aspect ofthe Inex Finger Casa Spl Thicknes hin Grat 38 Pater lap), Fll-Thickness Skin Graft 37 Neurovascular island ap from the Distal Ulnar Aspect ofthe Rng ger (Aa Pattern Prodecures wit Small Local Skin Faps 33 Flap) “Plasies 38 Sil 2p 38 Large Peeled Axial Patter Skin Flaps. Contiuaus Malpiepasy 40 aeuinal Hap Reverse Zplasty (Buttery ap)... 41 Rall Frear Fap| vevepastis ry Palmar V¥ pias (Al ater Microsurgla Free Flaps rap) 43 Tara Upper atm ap Bilateral pissy (ial ater Fup) 444 Injuries and Secondary Changes ofthe Finger- Volar avancereat ap onthe Tham wit Ful-thickness Skin Gat (Axa Pattern ‘nator ap) 45 Teatment of fnjuries tothe Fingernail and Nall Volar vancenent ap onthe Thumb wi Bel a V-¥-plsty (Axial Pater Hap). 46 treaiment o's Subungaal Femara Volar Advancement-Flap onthe Other tan ‘Treatment af Crush Ingres tote Wa Bed the Thumb Fingers (Axil Pattern Flap 47. Treatment of Secondary Changs nthe Fingernail ross Finger Flap (Random Pattern fap)... 48 and Nall Bed Reversed Cross Finger lap (Random Pte ‘Treatment ofa Spit Fingeral ap) 50 Naieied Grae Dorsal Vascla Pedicle ap (Axa Patan Treatment of aychoaypsis ap) 82 38 34 7 60 50 8 6 5 oo 6 0 % 7” n n 2 2B3. Microsurgery Microsurgery ofthe Peripheral Nerves ‘Anatomy of the Peripheral Neves ‘Types af Nerve Inures Complete Nerve Divison (Newiormesis) Histopathologic Changes inthe Nerve stumps Surgical Tecnigues Epineural Suture Perineural Suture Nerve Graft : Example of a Nerve Graft Using the Sura Nerve Microvascular Surgery ‘Applications Replantaton : 4 Compression Neuropathies Compression Neuropathy ofthe Median Nerve bratomy Funtion China Pics Comoression ofthe Median Neive atthe gic ment of Struthers Compression ofthe Median Nerve atthe Bicipital ‘Aponeurosis Pronator Syndrome [Anterior Interosseous Nene Syirome Carpal Tunnel Syndrome ‘utnae Nerve Compression Syndromes ‘anatomy : Function Clinical Pte : 5 Tendon Transfers “Median Nerve Palsy Function Clinica icare Proximal Median Nerve Palsy ‘Surgical Principle Distal Median Nerve Palsy ‘Surgical Principle ‘Ablcta Dit Mini Teaser ‘Transfer ofthe Flexor Digtorum Superficial ofthe Ring ger ‘nar Nerve Palsy Function lineal Picture Proximal Ulnar Herve Palsy Distal Ulnar Nerve Palsy : ‘Surgical Principle 16 78 ” 7 7 7 * n 0 8 8 8 12 m2 m2 2 us 20 12 133 126 28 26 26 145 145 145 us 145 145 135 148 9 158 ist 134 134 154 134 Contents ‘vascular Bundle Grafts Donor Site ofthe Thoracodorsl Avery and Vein free Toe Transfer Pallczaion surmeal Tecniges [terial End to-End Anastomosis for Similac Sie Vessels ‘terial End-to-End Anastomosis for Dissimiar Size Vessels ‘Aerial End-o-Side Anastomosis ta Elastic Arteries ‘eral Ené-to-Sde Anastomosis in ‘Arteries with Artenosceronie Changes Interpose Vein Grits Compression ofthe Ulnar Nerve at the Elbow Srpla Treatment Options Subcutaneous Transposition ‘compression ofthe Ulnar Nerve inthe Wrist, (Guyor's Canal, Radial Nerve Compression Syndromes ‘anatomy i. Function linia etare| ‘Compression ofthe Radial Nerve at is Point of nay into the Lateral HumeralItermuscular sepium . Posterior inteoseous Nerve Syndrome ‘Wartenbergs Syndrome Static Corection ofthe Metacarpo Dhalangeal Join with a Zancol Capsulotess| Dynamic Correction afte Metacarpo phalangeal Joint withthe Fexor Ten Sons Dynamic Correction of the Metacarpo- phalangelJont withthe Extensor Tendons Transfer ofthe Extensor ndicis uscie Tendon Radial Nerve Palsy Proximal ada Neve Pals Function China care Surgical Principle ot 105 103 105 106, 10s. 130 130 130 13 135 135 133 Bs 138 139 ma 154 158 161 166 166 198 188 168 vilContents Merle dAubigné Tendon Transfer Distal Rahal Nevve Palsy ‘Combined Median and Uinar Nesve Palsy unction Proximal Combined Median and tinae Nee Paley ‘Gini ietare Surgical Principle Distal Combined Nledian ad iar Nerve Palsy Cleat Pierre Sutpcal Principe Transfer ofthe Exiensr Indies and 6 Tendon Injuries Suture Material and Suture Technique ‘Core Sutures Pullout suture Pullout Wire Modied Krehimayr Stare Z-Shaped Tendon Splice Advancement Bunnet Suture Incerlace Suture (Paivrtai) Extensor Tendon injuries ‘Anatomy and Tendon Zones Treatment of Acute Injures Fingers Cassifcation of Subcutaneous Extensor Tendon injuries in Zone Ddt and Da, Zone Da ‘Avulsion ofthe Extensor Aponeurosis ype) ‘Consevatve Treatment Surgical Treatment Attachment with Pullout Wie Auulsion of the Extensor Aponeurosis ype it). ‘tachment with Paloat Wire Attachment with Wire Suture Palmar Fracture Dislocation of the Distal Imerphalangeal ine Type W Pin talizacion with Retrograde Driting Technique Zone Dd 2 Closed Rupture of tne Extensor Aponeuro™ sis Type Conservative Teatment ‘pen Injures tothe Extensor Aponeurosis (ype) Tendon Suture Zones Dé and Dd 4 Isolated Avulsion. Bony avulsion or Cased Rupture ofthe Medial Part of the interme sate Band Conservative Treatment Attachment with Pullout Satire Tendon Suture vil 168 3 m4 1% 4 4 114 175 18 15 180 180 im 182 183 185 186 188 189 190 183 m 193 194 194 194 194 195 196 196 196 197 197 199 199 199 199 199 200 200 200 200 aor "Extensor Digit Minin and Tendons Radils Longus Tendon Riordan vor Carpi Radilis Tendon Transfer Flexor Digiorum Supericiais Tendon ‘Transfer Casto Fixation") Brachiocadiais Tendon Tranter Opponens Pasty Using the Tendon of ‘he Extensor Inics Opponens Pasty Using the Tendon of the Extensor Carp Radial Brevis, 15 175 115 15 18 15 5 ‘Avulsion, Bony Avulsion, Closed Ruptie, ‘9 Laceraton ofthe Mecial and tateral Pats ofthe Intermediate Band and the Lateral and Dorsum of ce Hand one Dé S [iceration of the Extensor Tendon a the Level ofthe Metaca'pophalangea Joint “Tendon Repair with Core Sutures ‘Tendon Suture with Pallot Suture Zone Dab {craton of an Exiensor Tendon Prosimal to the intetendinous Connection Tendon Suture Using Modified Xirchmayr Teennigue Extensor Tendon injures with Defects Proximal tothe Intertencinous Connection Bridging Extensor Tendon Delects Weist ana Forearm ‘Zone Dd"? laceration of the Extensor Tendon inthe Tenvian Suture Zone 048 laceration ofthe Bxienior Tendon inthe Forearm Tendon Sure ‘Thum Gosed tendon Raptures in Zones Pat and Pez Conservative Treatment Tendon Suture ‘Treatment of Poorly Heald injuries All Fingers Zones Ba 1, ii ana 3 Insufficiency ofthe Extensor Aponcureis ‘Due to Searing in the region of itl) Incerphalangal int Sar Shortening to Reconstr the Extensor Aponeuross Zone Dds Insuciency ofthe eda Pato the Inermediate Band Due to earring 201 208 203 203 203 204 2s 205 205 207 207 209 200 209 210 20 210 an 2 22 22 22 20 213 213 23 25 asPathoanatomy Reconstruction ofthe intermediate and by Reflecting 2 Tendinous Flap (0 Restore continelty Reconstruction ofthe intermediate Band with Tendon Grat Zone Das ‘Rupture of the Extensor Pols Longs tendon “rans of the Extensor Indies Tendon ‘lexor Tendon injures Preliminary Remarks ‘Anatomy and Tendon Zanes ‘Treatment of Acute Injuries gers “Zone Oi Forms of injuries Fvulson ofthe Tendon of the Fixer Dig torum Profundus Musee frm the Distal Patan ‘Attachnent with Plo Suture ony Avulsion of the Tendon ofthe Fexor Digtorum Profundus fom the Distal Phalanx vith AaitonalAvulsion ofthe Tendon trom the Bone Fragment Tnvernal Fixation ofthe Avulsed Bone Fragment and Attachment ofthe enon of the Distal Palant sss... Laceraton ofthe Tendon ofthe Fexor Digitorum Profundis Muscle in Zone Dp 1 ‘with Short Distal Stump “Advancement in Zone Dp 1 Tendon Suture in Zanes Dp i and Dp2 Zone Dp? TeoatedLaceaion of the Tendon ofthe Flexor Digitorum Profundus [iceration of Both Fexor Tendon Tendon Suture 7 Fractures and Dislocations enerat Finger, Excluding the Thumb ‘Anatomy Treatment of Acute injures Fractures ofthe Distal Phalsas "Tue Fractures Conservative Teatment Removal of the Fragment shat Fractures (Conservative Treatment Pin Fixation sla and Aria Faces. (Conservative Treatment | Pin Fixation Screw Fixation as 216 28 20 20 2 223 223 2 26 26 226 26, ns 26 a am ns 228 no 20 230 231 2H 265, 253 287 367 267 267 207 269 267 287 268 268 268 268 Contents atm ‘ones Dp 3 and bp 4 Taceration of Both Flexor Tendon “fencon suture ist and Forearm “Zones DPS eration of ai Flower Tendons “Tendon Suture Zones Bd Through Du 3 Postoperative Management to Enhance Rnetional Rehabilitation (Kleinert), itera Flexor Tendon Sature inthe Fingers Thum Zone PI sed Injris tothe Tena of the Foxor Polis tongus [iceration af the Tendon af the Hexor PollcsLangus with a Shor Distal Stump ‘advancement Zone Pp 2 ‘aceraton of he Tendon a the Flexor Poles Longus atthe Level of the Proximal Phalanx Splice Advancement ofthe Tendon Tendon Suture zone Pp 3 Taceration ofthe Fexr oii Longs ‘Tendon in the Thenae Region “Tendon Suture Zone Pp 1 thvouth Pp 3 Postoperative Management to Eibance Functional Rehabilitation (Kleiner) tera Flexor Pllc Longs Tendon Suture “Treatment of Pooty Head lnjries ‘Chronic Flexor Tendon Lacerations Immediate Tendon Graft Two-Stage Tendon Reconaclon, First and Second Stage “Tenodesisin Zone Dp 1 Injures to the Capsular Ligaments ofthe Distal Toterpalangeal Joint uptore ofthe Collateral igamiens or Volt Prate ‘Conservative Teatment Combined Ligament Rupture (Dislocation) ‘Consevative Treatment Reconsnctions of the Ligimenis Fractures of he idle Phalanx Condvlar Fractures (Conservative Treatment Pin Faavion Screw Fination sate Fractures (Conservative Teatnent in Ftaton 24 2a 2a 24 27 237 337 2 29 29 20 240 2a 2a 241 2a 22 2a 2a 2s 245 245 2a 2a 2a 248 Das 248 2st 269 260) 269 269 269 269 20 20 20 270 20 mn m coContents Wire suture Screw Fixation Bastar and Ariular Faces. ‘Conservative Treatment Pin Foation Screw Fixation and Canclios Gra Injuries othe Capsular Ligaments ofthe Prox ‘mal interphalangeal fine Rupture of the Collateral Ligaments (Conservative Treatment Ligament suture tion ofthe Ligaments Rupeure ofthe Volar Plate Conservative Treatment Comisned Ligament Rupture (Dislocation) Conservative Treatment Reconstruction ofthe Ligaments Fractures of the Proximal Phan Coneylar Fractures ‘Conservative ieatment in Faxaton Screw Foation Comisined Techie Shaft Fractures Conservative Treatment PinFisation Serew Fation Stabilization with External ator Basil and Artiular Fractures {Conservative Treatment Pin Foarion Screw Fhation Combined Teeaigie Plate Fixation Injuries co the Capsular gare of the het ‘arpophanlageal Joints of te Fingers, Excluding the Thum Rupture ofthe Cee igamenis Conservative Treatment Fxatin of a Distal Ligament Avision ation of Proximal Ugament Avul- Rupture of te Vata Pate ‘Conservative Treatment Rupture ofthe Collateral Ligaen and Volar Plate: Dislocation ofthe Metacarp- Dhalangeal Joint Conservative Treatment Reconstruction ofthe Ligames Treatment of Perly Heed injuries Distal nterphalangea Joints Tnreparable Join Damage Tension Band Artvoesis Proximal interphalangeal Joints Instability ofthe Collateral Ligaen. Ugament Reconstruction by Sar Reinforcement Volar instability Superficiatis Tenodesis Inreparable Joint Damage’ “Tension Band Artrodetis Lag Screw arthrodesis m 23 24 an 25 26 2 on a 279 280 280 280 280 280 280 2st 281 281 281 281 a2 283 283 283 234 234 286 26 286 286 287 288 22 292 295 204 294 24 24 295, 205, 295 296 296 208 298 500 Metacarpophalangeal Joints of the Fingers, Excluding the Thumb Instablity ofthe Coliateal ligaments Volar inetbicy Shortening the Cental Sear ‘Metacarpals of the Fingers, Excluding the Thumb ‘Anatomy Treatment af Acute Features Fracturesof the metacarpal oie Fingers, Excluding the Thumb ead Fractures Conservative Treatment Screw Fixation Neck Fractures Conservative Trestinent PlateFixation Pin Faation ofa Separated piphysle Shatteracures Conservative treatment Plate Fation Screw Fixation Pin ation Stabilization with Exerral nator SBaslarand Arcular Fractures Conservative Treatment : Fracture Close tothe Metacarpal as. tated inthe Little Finger ‘Screw Fsation Plate Fhation : Bony Avulsion ofa Tendon, ascrated inthe Second and Fit Metacarpals, Screw Fxation Tension Banding Fracture Dislocation ofthe Metacarpal ase with Bony Ligament Avision, state n the ith Metaarpal Bennetts FractuteDislo- ‘tion! in Fixation : Compression Fracture te Mietacarpal Base, Iystratedin che Thira Mecacarpals (Combined Technique Injuries othe Carpometacarpal joints of te Fin: ses, Excluding te Thumb Tears and Atulsions ofthe Campmetacarpal Ligaments ‘Consevatve Teatment Usamentsucure Screw Fatlon of ony Ligament vulsion Treatment of Poory Heald injuries Malrotation of the Fingers Fllowing Metacarpal Proximal Phalangea! Fractures, Derotation Osteotomy Thumb ‘Anatomy’ Treatment’ o Acute injuries Fractures ofthe Phalanges Injures to ene Incerphalangea joint Injures tothe Metacarpophalangeal joa the Thum’ 303 303 303 303 305 5053 306 306 306 308 306 307 307 308 308 310 310 310 an. 313 aa 315 315, 315, 318 316 a6 a6 36 318 38 us 38 220 320 320 a 321 Eva a2 322 326 26 0 330 20Injures othe Ulnar Collateral Ligament (Clssifieation of Usa Collateral Ligament Injures inthe Tourn Treatment ofa Rupture, Avision or Bony ‘vulson ofthe Ulnar Collateral Ligament of fhe them Conservative Treatment Repairof an intasubstance Rape ‘with Ligament suture Foation ofan Avulsed Ligament with a Palloat Suture Through te Bone Foatlon ofan avulsed Liameat (with ‘orwithout a Bony avulsion Fracture) ‘tha Pllout Wire Trough the Bone ation ofan Avulsed Ligament with Bone Suturesvia Anged Drill oles PinFiation ofa Distal Bony Ligament pvulson Screw fixation ofa Distal Boy Liga ‘ment Avulsion . Pin Fationof Proximal Bony Liga- sent avulsion Injures othe Volar Ligaments ofthe Metaca pophalangeatoineof she Thum Classification of juries tothe Volar Ligaments ofthe Metacarpophalangeal Jeantof the Thumb ‘Treatment ofa Rupture Avision oF Bony Avision ofthe Volar Ligaments Conservative Teatment ration of roximal Avision of the ‘Volar Longitudinal Ligaments with a Pullout suture Trough te Bone Repair ofan avulsion ofthe Volar Longitudinal Uigament rom the Sesamoid witha Ligament Suture Repair ofan avulsion ofthe Inter~ Secamoié Ligament fom the Sesamoid ‘with igamene suture Pia Fcation ata Bony Avuson ofthe Intersesamoid Ligament rom the Sesamoid witha Longitudinal Sesamoid Fracture Fractures ofthe Fst Netacapal Head and Neck Fractures Shaft Fractures ‘Conservative Treatment ination Pia Fsation ° Fest Metacarpal Base Fractures Fracture Close tothe Bare, Distal the Insertion ofthe Abductor Polls Longus Muscle. : ination Pate Faation Fracture Close to the Base, Proximal the Insertion of the Abductor Poles Longus Pia Fxation| PlateFixaion ‘racturDislocatan of Fist Ntacapall base: Bennet ractre Dislocations ‘Conservative Treatment 230 330 a a1 a cry 336 a8 238 339 a9 339 20 3a a0 aaa as us 345 us 345 548 3a7 aa 38 349 350 350 351 351 Contents Pin Fixation 352 Screw Foation 352 compression Fracture ote Fist Ntacar- pal ase: Rolando’ Fracture 353 Pin ation 353 Plate Fixation 354 Harvesting Cancelous Graft from the Distal Radius 355 Injuries tothe Fst Carpometacarpal joint." 356 Dislocation 355 Conservative resent 336 Ligament suture 357 ‘Treatment of Poorly Heaed injuries 358 nar Instability ofthe Metacarpophalangeal Jointof the Thumb 358 Reconstruction f the Uinar Caiateral LUgamene 2 358 Volar instablty ofthe Metcacrpophalangea Joint ofthe Tum Reconstruction of Ligaments fr Vata Instability 360 Instabiliy ofthe Pst Carpometacarpaljoine + 363, Reconstruction af ames 353 wrist 365 ‘nator 365 ‘Treatment of Acute injuries 538? ‘Clssitcation of Dislocations ad Fracture Disio- cations . 367 Fractures ofthe Wrist Bones 37 Fractures ofthe Trapentum mm ‘Conservative Tate a Serew ration a Fractures ofthe Seaphold a4 Cassfieation of Hactures athe Scaphoid -. 374 Location of fractures ofthe Scaphoid 2... 374 TWeatment of ractres ofthe Scaphoid <=» 374 ‘Conservative Treatment 314 Surgical Treatment 374 Injures othe carpal Ligaments 315 Clssfaton of Carpal Instability 315 ‘Treatment o Carpal instability 35 Paral Instability of Joint (woated Carpal Ligament inury) .- 375 ‘Conservative Treatment 36 ‘Closed Redvetion and Pin Fixation «== 376 Fxation ofthe SeaplunateInteros: seous Ligament 3 ‘Triqutrolonate stabi 38 Concervative Treatment a8 Closed Reduction and Pin ixation ==. 378 Fination ofthe LunoriqutrlInteros: Sseous Ligament 319 Complex instatlity fa ont Regional Car palLigamentinjury) x79 ‘Seapholutate Dissociation 319 Conservative Treatment -cnncesess 380 Closed Reduction and Pin iation =. 380, Screw Fixation ofthe Scapolunate Ligament 381 Fixation of the Scaphalunate ligament ‘vith Bone Suture via Angled Drill oles 382 x!Contents Suture ofthe Scapholunat Liament Faation and Suture ofthe Radiosea- hocapate Ligament Compe istabiry of Severai joints (Bx tensive Carpal Ligament Injury) Perilunate Dislocation ‘Conservative Treatment ‘Gsed Reduction and Pin Fixation Suture apd Fixation ofthe Carpal Liga ‘Treatment of Poony Head injuries ‘seudarthrsis in che Carpal Bones ‘Seaphotd Pseudarthross Volar Apprach in Scaphold Surgery Russe Bone Grate Herbert Sere Fixation Ender Pate Foation Pochlaner-Husl Vascultied Bane Graft agp tnt ‘eapholunateisibiyy Dorsal Scapholunate Ligament Recon” sructon Dorsal and Volar Ligament Recontrue- tion in Seapholunate Dissociation Radioscapolunate Ligament Recon ‘Wrist and interearpalAtivds Plate Arthrodests of che Wit and Carpal Joints Radius and Distal Radioulnar Joint -nstomy 8 Rheumatoid Disease, Degenerat Avascular Necrosis, Instabilities, Fingers, Excluding the Thum Distal interphalangeal Joints Rheumatoid Artis and Erosive Osteoar= Uts with Heberden's Nodes ‘arhcodesis Proximal Inerphalangeai ins Reurate Artis Synovectony Arthroplasty ‘rhrodesis Distal Incerphalangeai snd Proximal inter halangea Joints Rheumatoid Arthritis sind outage Defority Surge Corection ofthe Boutonnigve Deformity “Metacarpophslangel Joints Rheumatoid Arts ‘synavectomy, Arthoplasy Xi 382 386 386 386 387 387 389 380 380 389 389 392 392 394 337 397 08 400 402 405, 405, 208 Treatment of Acute Injures Fractures of the Distal Rags Chssifcation of Fractures oft Distal Radius Treatment of Factres ofthe Distal ads Conservative Treatment Pin Fixation Percutaneous Serve Fixation Stabilization with Extemal Fastor Pate Fisation Through Volar Approach Plate Fixation Though a Borsa Appreach Piste Fixation Trough a Combined Volar and Dorsal Approach. Injures ro te Distal Radial oie Fixation of the Teangulat brocar- tlageinan Umar Avusion| “Tension Banding ofa Bony Avision of the Trangular Fibrocartage ina Frac- ture ofthe Ulnar Stylo ‘Treatment of Poorly Heald Injuries Distal Raia! Deformity ‘Osteotomy to Carect a Deformity af the Distal Radius Sauve-Kapandj Athvodess ofthe Dis! ‘al Radioulnar Joint with Segmentat Ulnar Resection Chronic tstailty ofthe Triangular Fiboca sage Pocilaner Decompression Gxteatomy ofthe Ulnar Head ive Changes, Stenosing Tenosynovitis, 409 409 409 43 43 45 a8 419 a 28 a 42 43 aaa a4 38 38 43 48, Wrist Ganglia, and Dupuytren’s Disease as a8 a8 as a1 431 431 454 459 462 462 4682 486 466 470 Rheumatoid Arthritis and Swan Neck Deformity Intrinsic Release Retinacular Reconitracion. Extensor Tendons ofthe Fingers, Excluding the Tham Ruptures ofthe extensor tendons Side-to-Side Sutures, Tendon Transfers, and Free Tencon Grafts Fexor Tendons of te Fingers, Exchiing the Tham Renate Arts oF Tenosynovitis ‘Synovectomy ofthe Flexor Tendons ‘Ruptues of the Fexor Tendons ofthe Fine gets Excluding the Thumb ‘Synovectomy, Tendon Transfers, nd Fre Tendon Grafts Stenasng Tenosynovitis or Tager Finger 'Ai Pulley Release and Synovectomy 478 a8 479, 492 482 486 86 486 490 490 492 42‘Thumb Metacaepapisngeal joint of te Thums ‘Rheumatoid Artis and Boutonniere Detority ‘synovectomy ‘Athrodes txtensorTendons of Thum Ruptures of Extensor Tendons “ranser ofthe Extensor indils Tendon Fexor Tendon ofthe Thumb Rupee ofthe Tendon ofthe Flexor Polis longus Muscle Reconstiction witha Free Graf fiom the Palmaris Longus Tendon «... Stenosing Tenosymovitis or Trigger Thumb "Tendon Sheath Release De Quervains Disease “Tendon Sheath Release First Capometacarpal oi “rth ofthe ist Carpometacaipal Joint ‘Ashworth batt Arthroplasty ofthe Fist Carpometacarpal Joint Resection Interposton Anhropasty vith an Autologous Pedicled Graft Contents ao a4 494 aod a8 500 500 500 503 503 506 506 508 508 510 510 510 sia Metacarpals Dupuytiens Disease Rescection ofthe Palmar Aponeursis Wrist Waist ins Rheumatoid Artiits ‘smnovecomy Radiotunate artnodesis Arthroplasty Arthrdesis of the Wrist Joints Instability Artis and AvaseularNecro- ‘Sciponrapeato- Trapezoid Triscaphe) arthrodese Scaphoia-captateArtvodesis. Wrist Ganglia Resection ofthe Dorsal Ganglion Resection ofthe Volar Ganglion Bibliography Index 518 318 518 524 524 54 504 50 52 5a 546 sas 58 550 550 553 556 558 xill1 Systematic and Topographic Anatomy1 Systematic Anatomy Systematic Anatomy Passive Structures ‘Skeletal System (Figs 11-16) Fie Lt anes of the hand 4 si per aed eco Foran 1 5 pc it a 12 ones ofthe hand eer a 2 Ee ae Bb ballotPassive Structures 13. ones of the hand Figs 14a and Bone fhe fang agers (ie finger) adsl aspect, 2 ool sect, Badal pce 1 agen 2 Raeaot api 1 bard tle) 5 ope 2 betel 4 fan 5 toc ne ae 5 Sp 4 aot ne recy 5 pats ac 4 6 Poa he 8 Se recs te ts 5 Feast arp 3 ee 4 thie meacaral too W Cte 5 Metal te nme 18 Spa pce fed macs 1 Came 0 Cota1 Systematic Anatomy j Fis 15a-e Bons of he long fingers (lenge) 2 besa ectPassive Structures Ligaments (Figs.17-119) Fgh 7aand Ugements ofthe hand} O20 mtoons genes 1 lean ote eter cans Donal apt 2 Paton netcnpa igor met operat tne 4 eimchiermremrrnis 1 Une ein toe & Deep plane 4 en ofthe enter capirecats 35 Bl aula gree 5, a exponen igre ‘ian 1, ana gm ener ni)1 Systematic Anatomy Fis. 19 ronal wrist (aio artulton, dosed i Boral apect 2 aot aire {Siege teoscos inet tiestnasccigene F110 Dia interphalangeal joint 55,112 Mtacapoptaloageal jot of lng ager eal spc il pee 1 mrs ote edn heath pA an 2) 3 Arr parasols a A) 2 a tromae meen 2 Externe rng she 3 Giecventgenee 3 it pase 4 Peep 5 peer art Cele genet 1.31 Prox interpalanges jot ape 5 Ar rtf fr eos tis 22, and 4) 2 Gre purl he tenon seth ge 1 Phage ee ear iret 4 Gectren igo 1 oer pan 6Passive Structures 1.213 Mhscaar insertions at the metacarpophalangeal Jott of he tam Soros 5 ities opted 3 rid 2 Stet P aati 3 Spm ns ig 115. Muscle ingrtions at the mtcarpophalangca Joint fee thar Bison ape fg, 14 Metacarpphalngea aint f the thu Nelo pet 3 Pein tli 6 fem 2 Giemsa 5 Eptindene 2 Fo a hte pl Igarent 6 arin ee ia" | Bea Lee, See gee be ieee Pee feue Roe1 Systematic Anatomy Hig 18 Musclar Insertons at the metacxpophaangeal ric. 1.17Atacarpophalangea jit ofthe thumb Joint of he tm Ua sie, tina ose co plies 2 hor lng pina inet 1, Shoe aa 3 heehee 3 Key tes one ig. 1.18 carpometacapa jit af the thumb Ft rvonetnaa tf esha Bowl eps ears er ge 9 SonaetacspalinmanActive Structures Active Structures (Figs. 120-126)1 Systematic Anatomy Marler and tendons of the handsages escapee et Active Structures Fie123_oesalapancuresis of the nde finger rl ape, a 1 Be am Foaman 13 oi ees re {loser sexe patient 5 Ko ate lc po me 5) eect ecm itn made ender se‘Systematic Anatomy i. 1.24 Fleer tendon sheath of lng finger 19.225 oul poner oben fa aspect Davata 5 Péter lor) Rao eat ne 2 Dep tenene etc 2 Sout apnava 5) Tedonsl th fe dgtrorreste 5 Fecnette etern pote bee 1 Execs tor agnor 1 Sorento & ister genet 5 mst ha othe act ple 5 Fedora ene 3 ftoomi eames o kerio ea omg om ta( Figs 1.268 andl Finger Ula eect, 2 With sho apd sudataneos tue removed 1 Opponent! ii apse ae reftng he ‘dear di nian the evar it mine bess Active Structures . ae eae, oases 31 Topographic Anatomy Topographic Anatomy Regional Topography Forearm (igs.127-132)Regional Topography g.129- Waar aspect ofthe forearm, subcutaneous ayer 9.1.30 Voor aspect of the forearm, supefial subfasci1 Topographic AnatomyRegional Topography Dorsum and Palm of the Hand (Figs 133-138) Fig 133_orsum of the hand, sbeutaneous "he dsl vero ea as ban rest eompearenoved fhe nar cts var)1 Topographic AnatomyRegional Topography1 Topographic Anatomy Long Finger (Figs 139-142) io 139 Dorsal aponeuross and cutaneous ligaments of + 5-140 flexor tendon sheath and cutaneous Uapmens of & tong finer {ong finger Dona space Vela + cabs ig 1 ton ast 3 ee taney 2 Goer emer 3 er eer tl ee pg he daa 20Regional Topography1 Topographic Anatomy ‘Topography of the Nerves of the Arm ‘Median Nerve (rss. 144-148) Fig 144_ origin and course ofthe mean nervein elation to Fs 1453°<_ Medan nerve in relation tothe pronatr tres eiceon Disease omens se 1 ahem aie eter or oe eee a tee, — 22ios 1462 and. Variants ofthe course of the median nee lnthe pronto teres du toa supracondylr proces (pro 3 2 hatonsip tthe bones Bight pont tres 3 Stpecontiiepeaces Topography of the Nerves of the Arm ig 147 Course of the median nerve nthe pl of the hand cam col ain ee tht ee See gt ee ‘ci en on Fg 148a-< Orin an course ofthe muscalar(theae branch ointatanmento He 68) B Sibigamertoes pe (13) Tangumenous pe 313) 3 ie a 5 cate tea anh 231 Topographic Anatomy Ulnar Nerve (Fis. 149-151) F149 Ong and couse ofthe una eee in relation to ‘he boner af he am 4 Deep bnch 24Topography of the Nerves of the Arm Fig 1S0aand Schematic lagram ofthe course ofthe ar 1 Pima rpc of he rear appl f te hand 1 Cayo a 2 Cama pia dated ees » enn pam longs P15) gee me 5 Rh 9 ow ott ee mene 251 Topographic Anatomy Radial Nerve (Fis. 152-154) | ig, 152_ Origin and course ofthe ada nerve In celstion to Fa, ofthe rail ere tnough the regions ofthe I {he bones of te arm ‘am an forearm | i 26Topography of the Nerves of the Arm Fo 154. course of tho deep branch ofthe raat nore ‘through the spinator pane seen See eee Shor 21 Topographic Anatomy Cross-Sectional Anatomy (Fis.155-161) fete attenCross-Sectional Anatomy fig,157_ saga section trough Jong finger ofthe hand rd digit) 291 Topographic Anatomy 9.158 Asal scion though the dtl forearm 1 Antares ae (nein ee) $e dota es 18 Sent ee aterm apts 1 Rodintt pans 2 fiero 2 Une ote cto re msedosanes ner) 1 Sacre he 3 Steno pts ow aaa 30 "eens agen ie ini en 12 rrr Sct hen ene 2 se 2 ee crore rn 3 ietaeetesee SaCross-Sectional Anatomy pe een dt mn 4 Fett ee a iper dkmers| 2 wee te 1 Conn pt i ee ne "5 Spon pe 1.60, Ail section tough the dtl carats 32 Tonbn fe for copiee 1.61 Asal section doug he meta acpi te ak geRses 3 Bendimenan tees 2 umbrate 17 tae lit) 2 techn 28 Sree fear dgnmamime 1 MieSystematic Anatomy Fig. 161s scion through Th metacpepnges oa hea es Red 1 sil ete i oe 2 de ens 16 Tete fe i pu si i EEeaoe Sa ise 3 xoarsamc 322 Skin and Soft-Tissue Injuries 332. Skin and Soft-Tissue Injuries General “The structure ofthe integument of the hand vates. The war epidermis is thick, contains numerous sven ands, atl corpuscles and melted orpuseles ot ho hair or sebaceous glands. The dorsal epidermis i thin, can be raised in folds, and contains hata Se baceous lands. 34 Reconstruction o ost ares of skin onthe hand is partc- lary important co protect undecying structures and 9 ‘estore the sensitivity ofthe hanSkin incisions Skin incisions ‘kin incisions ae determined by the position of static hand lines and cutaneous olds. Asin nesion should never course perpendiculaely across 2 Mexion cease ie 20), » 2 Sannin nthe pm fhe and Sin incios nthe dorm of he hand { Skninclns nthe Gor fhe hand 4 Later sn nen he ger 352_Skin and Soft-Tissue Injuries Free Skin Grafts Preliminary Remarks Split-Thickness Skin Graft sitskin: Consists oeidermis and portions ofthe det Skin grafts require a wound bed with good vascular SP Supply. Full-hikness skin grafts are sed to caver small oF varying thickness, defects thicker splteskn grafts are use for ltger de- Removal From the frearm ortigh with a dermatome, a Management: Removal siti covered with a fine mesh nonadherent dressing The woud will heal by «pon ‘Anatomy and Types of Skin Grafts taneous epithelazation in about 10 days (fig.22) Fi.22 Skin and sn rats 1 eps of he vas sn grat 2 Pyro Per canen ieee 4 Sete cant 36Free Skin Grafts Full-thickness Skin Graft (Figs.23 and 24) 1 Full-thickness skin: Consists of epidermis, the entire ‘dermis, and portions ofthe subcutaneous faty tse. Remova: Grafts are removed witha scalpel. Small de- fects ae closed lth skin fom the forearm, larger fects with skin fom the Inguinal region, Management: Primary closure of the removal site i in- dicated Surgical technique: Fig.24 0.23. Shin defect on the proximal phalane ofthe nex fine bat aspect 5 ger day a 4 4 he a a. a ® Fige24a and b_ fll thidnes sin aa fb Te satus at nr foam ruber presse bandon Pring a fabtcnes sm ga th retention Stes bine the ga 372. Skin and Soft-Tissue Injuries Procedures with Small Local Skin Flaps Skin Naps should be use to close and stabilize skin de. fects with a poorly vascularized wound bed and exposed tendons and bone. We ierentiate between skin Maps with vascular supply tothe edges (random pater Naps) and skin laps ‘with vial vascular supply axial patter Naps). The aa Vessels make it possible to rene an especialy Tena, vwelvascilarized lap Monofilament suture (5-0 oF 4-0) is used, Sutures are ‘usualy removed after 10 to 14 days ' fo Fig 25. Scarcontractre inthe fest intergal space 38 ZPlasties 2plasies are a special form of skin Nap that can extend the skin longitudinally at che expense of width. This achieve by making 2Zshaped tnison and advancing the resting triangular Naps, The sides of the Z-past ‘must be of equal length 8 60-deyree angle can result 1 an increase in length of 70-75%. Maliple successive or Tevetsing Z-plstes can be performed, The rhombord flap described by Limberg is 9 special form of Z-pasty Simple Z pasty (Figs. 25-27) Indication: Scar contractures aross che joint in the fis. interdigtal space. Surgical technique Fig, 2.6 Postoperative management: immobilization in aster: ie, tabling hand bandage for one week,Free Skin Grafts Fin 26-€. Simple sty The wars comanatney ace and 97 created The stn fp» advanced sath resto he Sear se csi Silty oan acaneg 25 of pte iiapesrom ath ve shape sen cose Flos 2.7 and bSchomsle agra of simple Zpsty ~~ 1 Faty eee bance ‘ \ Flay ser sdanceme 392_Skin and Soft. ue Injuries Continuous Multiple Zesty (Pgs, 28-210) Indication: Long car contractures onthe volar aspect of the hand, ‘Surgleal technique: Fig, 29, Postoperative management: Immobilization ina ster- ie, stabilizing hand bandage for one week. [296° Canina maple ay Te strisconenstly eee 1 Succession 9 shed sn nos are made The es of ach Zs be fel ert at angle of «The Zshaped skin pete sane 9.28. Searcontrature onthe nex finger2 Skin and Soft-Tissue Injuries Continsos Multiple Zloty (Figs.28-2.10) Indication: Lng scar contractures. onthe volar aspect of the han, ‘Surgleal technique: Fig.28, ative management: lmnobl2ation ina ter- se, stabilizing hand bandage for one week F.294-€ Continuous mule Zplasty 2° the war constrtacy eed B ASoccesion af Shope sn inns are made. The eof tach Z ust of equaling at an ah «The Zshaped sn apse stance woFree Skin Grafts Figs 2302-€ Medel of as B Movaneaent eta ng cease reverse 2 psy (Battery lp) (Figs 2.11 and 2.12) Indication: Scar proximal the PIP joints or sear on= traces inte interdigital fol. Surgical technique: Fig 2.12 Postoperative management: Immobilization in ster- uv, j ie stabilizing and bandage for one week, Fig. 211 Sear contracture nthe the intertalspace2 Skin and Soft-Tissue Injuries onze. Reve Zaye a) inion dtl spt 8 eso, vl pt nd ede The trans lps are sanced tr dose, the per ‘rom prontal dtl t pert the bet pombe ronson oF te eagle, 4 esting ngtnseas th econsuctonof he eterna fo fcantcton fhe tr fod di venvv.plasties Palmar vet (An Patern Flop (Figs 213 and 2.18) Indication: Reconstruction of fingertip defects. Surgical technique: Fi.2.4 Postoperative management: Sterile hand bandage and Finger splint for 10 days a ® « ‘ 0.2.42 Stump of amputated finger The ry cone by dey aang the wards Ae 4 Shaped sn dose shed palmar hin aon othe ta pha & Theskin fap bilaed an spice of ubctaneaus tise ‘aha sels a pre eves Sop B2. Skin and Soft-Tissue Injuries tera psy (il Potter Hep (Fig 2.15) Indieation: Reconstruction of fingertip defects. ‘Surgical technique: Figs.2.15b-e ‘Postoperative management: Sterile hand bandage and finger splint for 10 days Figs. 2359-8 Batwa Vplasty of am amputated finger 2 Raped ions made tay om bh sides of he tal pate in the apt ge tmp € Bethneuracl sf are mized and ache They fee then need ng the median ne «The stump covered th shaped donee san Ing the hn aps tothe ean ne Magnified view ofthe esecton of he aul pede 4 Magnes view ofthe neurons pele 1 ope pia il rer 2 Rope Sor eee 3 Rip otFree Skin Grafts \Volar Advancement Flap on the Thumb with Full: “Thickness Skin Graft (Axial Pattern Flap) (gs. 216 and 207) Indication: Reconstruction of age defects ofthe thumb up Surgical technique: Fig 2.17 Postoperative treatment: Sterile hand bandage wit ‘thumb spline for 10 days. The foam rubber pressure ‘bandage shouldbe removed on postoperative dy seven fig 217-4 Volaradvancemn pon the thumb ith ‘here sn gat “he pmar ips ct wh both neurons bares ghee 0.236 Amptated thumb stamp «Meneses ap mobitzed and adaneedto caer ‘ 2 Sint 4 Traps aban to com the snp, a te donee 3 lat i sein sane te atin ste scone wh ofan nat 452. Skin and Soft-Tissue Injuries Volar Advancement Flap on the Thumb with a ‘verplasty (Axial Pattern Flap) (figs 216, 2.174 and b, and 2.18) Indication: Reconstruction of elects ofthe thumb ip, Surgical technique: Figs. 2.172 and b, and 2.18, Postoperative treatment: Sterile hand bandage with ‘the thumb insight flexion. Figs 2388 nd boar advancement lp om the tam wn east "Tae pearac n ap mobi and adanced th a Vincion eve he stp, The dors od th 8 2 Poa par ga rey pe pa a aay a ee a ha ‘dab: 46 6 1 Aap shin clone coves the stamp ter aang theVolar Advancement Flap on the Other Fingers than the Thumb (Axial Pattern Flap) (Fes. 219 and 220 Indication: Reconstruction of large fingertip defects. ‘Surgical technique: Fig 220. Postoperative treatment: Sterile hand bandage with the finger insight fleson, 14.219, Amputaed finger sump Figs 2202 Volar advancoment lap onthe the agers ‘the thm 2 ate sm esin (0 2.14) 1 trai! pima sn lap is bid wth proxi neu ‘nar ed tling fre to pes the vase tures emerging he dos spect ofthe Map Tendon toe dara rine Nitra bate png fe oa tne einige leet ore {Theva perrsar ap coves the sump. The ger must ‘tay be pled in sgh eslon alow rion ee do ‘hes tenon ences consequent compere 1s peste Free kin Grafts a72 Skit and Soft-Tissue Injuries ‘ros Finger Flap (Random Pattern Flap) (figs 221 nd 222) Indication: Skin and soft-tissue defeets on the volar aspect of the proximal and middle phalanges of the fther Singers than the thumb. Surgical technique: Fi.222, Postoperative treatment: The ingeris immobilized ina splint for 2103 week, at hich time the fap is divided under local anesthesia, 5.221 Deep waar defect om the mide palo finger ‘The rconstucted dap flea tendon exposed. 48 Fig.2.226-d_ Cross ige ap 2 pedi ap Soba onthe dorsal aspect the agent fingerFree Skin Grafts IG) 1 ~] - : ¥ y LY ; i ¥ | ad p> 1 Thefupuithts bt pede plac owerthevlardsecty€ The cos ge fp cones the vor sin defect. te api the acer ger Fad th eto 4 The donor ste onthe dorsal pect henge cond with ‘Tatelaes agate The sre ns ofthe rein 5. tures are Kt kg forthe oo ber peer banaages2 Skin and Soft-Tissue Injuries Reversed Cross Finger Flap (Random Pattern Flap) (Figs 223 and 224) Indication: Skin and sofcissue defects on the dorsat aspect ofthe lng Tnger especially onthe proximal and ‘mile phalanges. ‘Surgical technique: Fig. 2.24 Postoperative treatment: The ingeris immobilized ina splint fortwo to three week, at which tine the Nap is divided under leal anesthesia Fig.228. Deep dorsal defect extending tothe bone inthe ‘mie phan 2 Sond 3 Sigma tac [0.224 eid cos ges ap he pane tiger op donpenlaied 208 rected to el the ec nthe nacent ge Th tc sn (gat crested sate asd to eo the deft ested 2 he ora ste. Ths procedure rere extemal earl daecion ‘th thes of maging oupe, 3 Spates sen gat boys 50 1 Dissecting the despite pt cnet asl defect tne adocent rer + xg cs tro casaFree Skin Grafts ‘ « é « Reape tates coment dh wd po cn wh et aoe IRs sin gra een ate 4 opine 1 Seana nae 5 Sorenson oak aes 4 h © ‘ 1 Thea sed hee woos ter The wound closed wth tention ates 512. Skin and Soft-Tissue Injuries Dorsal Vascular Pedicle Flap (Axial Pattern Flap) (fie 225) Indication: skin and sof-tissue defects on the dorsal aspect ofthe proximal and middle phalanges ofthe long Finger or on the volar aspect ofthe proximal phalanx of the long finger. ‘Surgical technique: Fig. 2.25. Postoperative treatment: The ingerisimmoblized ina splint fortwo to thee weeks, at whic time the Nap Is Alvided under local anesthesia, Figs. 2254 and Doral vascular peice lap ina deep drs {fect eatenang tothe one ofthe Finger 23° AtUp tha voscuse peice crest onthe acento Dasa beaches ofthe pins itl artery the ves sclera pater ap con 0b cat the Fatt second tnd pce Feit dt fy Botan dhe oe dg 2 note 52 1 The Fos placed oe the detect in the ace fs, The leno te dlc cover ths allies shin goRotated Advancement Flap (Random Pattern Flap) (Figs.2.26 and 227) Indication: Skin and sot-ssue defects on the mide and prema phalanges of the finger. ‘Surgical technique: Fig, 227, Note: This rotated advancement flap can be created as fn asl pattern flay that Includes the proper palmar ‘ig artery and vein Postoperative treatment: immobilization in str ‘Stabling hand bandage for one week. Fo2aramnd feted stance ap "bose ste shin Rap ths pron peice Free Skin Grafts Fig.236 sep volar defect onthe proximal plane . bb The fap insta a covert dee. The donor ste delet 532_ Skin and Soft-Tissue Injuries Hilgenfeldt’s Neurovascular Island Flap from the Dorsal Aspect of the Index Finger (Axial Pattern Flap) (Figs 228-231) Indication: Skin and sof-issue defects onthe volo ane dorsal aspects of the thumb, Surgical technique: Fig. 231 Postoperative treatment: The ingesis immobilized ina spline fortwo to three Weeks, a which time the fap i= divided under local anesthesia. "3.228 Deep war elect nthe data phlanc ofthe thumb 1g. 229_ Anatomy ofthe donor ste ofthe nerovscu ‘xtondng tthe bone Tan lap rom the dort pct ofthe sand ger shown ‘he schematic dogs in fg 230 54Fi.220.Sehemate ogram of the nro {Jva neurnara ap rom he proximal ph supply ofa Dl gaan Free Skin Graftsand Soft-Tissue Injuries 1 the neovascular sand fap coves the defet 56 fx 231a-e Rewrwasaar sand fap trom the dort sept ol teins ner ihe mera Wn pi dsc, tlng cate ope ‘re the petenon a he dono se Branching vse ‘rll evponed and ignte the pee petra eves Shot needy pepe ning Dap Mista ota Sy Dra aie nee ‘he delet cone with the flap ad daar te witha ‘hates sin Tes cons ae dosed rma.Free Skin Grafts Neurovascular island Flap from the Distal Ulnar Indication: Skin and soft-tissue defets of the thumb [Aspect ofthe Ring Finger (Adal Pattern Flap). (figs 232-234) ‘Surgical technique: Fig.234. Postoperative treatment: sterile hand bandage. The foam rabber pressure bandage should be removed on postoperative day seven. 0,232 Anatomy ofthe donor se ofthe meurovatele fig 233_ schematic dagram ofthe neurovascular soy of ttn tap rm the unr asguc of the ng ger shown nthe hela ap frm tea aspect ofthe ving finger Sema agro in Fi. 230 ro ne ' ‘gear rr me) ean) wa 6 Son ooh eral atey fal ay tho2. Skin and Soft-Tissue Injuries Fig, 23¢a-d_Newovsclr land ap rom the tal lnar [pet ofthe eng finger 2 Ohsetn a tenes ad fap wth magne ew rang’ naan of eth {omit plement of thea regres hosting ad ans Ing the ral pope alr geal sey a thei fre "Te reper palma il nee exposed td teres by ‘arf sping the pesneosom a separating thom the ermon dtl ene 1 Saal poe per gta tery 2 ope plot tl mane er) 3 Satna paraitl ee 5 smart 5 Bit at 2 Teka pt ogus 18 onan in Stas reson ree) Specular ban! aa stey Mito the neonse a p fro the ing ge "he prope! pala itl pee of eral fm tr sedi and bought dee opposition th the prope Pa ‘ar dgtl nee of th nd ap 58Free Skin Grafts «Shame dara and magni view renin te proper Palmar dtl nerve of he ada thm to sppesten with “he proper kos itl nee ofthe and ap Tene Snr fe pt oes oe ote smn fe ap ‘nh Senaton te thn, 4 Foe par ta eo eg age) The dtc onthe pana spect othe umd covere wth The revovasar Han ap he dono ite elec ores wit fultheiness si grt ane fosmebe presse Sande pps The sen esis sed pearly ith ‘stein soe, 592 Skin and Soft-Tissue Injuries Large Pedicled Axial Pattern Skin Flaps Inginal Fp (fg 238-237) ester reatmen Theorem fee in enn ecsinne Gael Woon wale baa Bras sae oe Indeaton tense skin and sotssuedetects inthe Eytan aes moe ies vane ‘thee weeks, at which time the flap is divided. Sarge technique: Fic 27 Nae: Te nia Np ea be slated athe super ‘itunes a ese tn cei fice fap oth mites nae '4.235- Deep sin detect with thesecond ad thedmetcar-Fg.2.36. Anatomy ofthe Inguinal gion palbones exposed ater intra ation wth plates Extensor ferdons have been pry reconstructed 1 ia os 1 Sle seeany onsen tel rate wt at) 60Large Pedicled Axial Pattern Skin Flaps ‘Around pad formed tthe bt of he gulp The ‘ot cnered wth the wel vse ap. The delet (fete atthe owe ns cael recy ah enon Fign 2372 Inguinal Fp anna ap of the esd see died ff the subeu- {Gres ot twa tome A thee he rar ‘pet ln pe the apn patn ofthe slat the store fo ene te the spe! crc Bac ary and vein ae aed diced ee a Se ermine iia The det sev, a the peed nul Tp sed com the dosem lthe hang 1 murat 2 Haba rpeee) 612. Skin and Soft-Tissue Injuries Radial Forearm Flap (Fgs.238-241) Very stir eincal criteria shouldbe applied to deter- mine i this procedure is inaicated the defect creates atthe donot site i a significant cosmetic impairment, land treduces arterial blood supply tothe hana Alterna tively this sciocutaneodsforerm lap can aleo be used a5 a free Map with mietorasculat anastomoses or 38 3 purely fascial ap covered witha split thickness skin [rN A portion ofthe radius bone may a0 be included Inthe Map. ‘The radial artery maybe preserved with smaller defects In the palm. The distal ofthe fascia foeatm, which Is Supplied by’ minor perforating branches of the radial atey, canbe rotated int the defect on a pee. 5.238 Donrsite ad possi acon ora peed a forearm flap to cover a defect on the desu ofthe hand 9.239. Sehematcdagram ofthe atrial blood spp to the forearm and hand ithe preenes of well developed ep sil pa es the mast fg cm 62 Indication: Large skin and sot-tisue defects over the dorsum of the hand and reconstruction of the thumb, ‘Surgical technique Fig 24 Note: The medial and lateral antebrachlal cutaneous nerves and the superficial branch of the radial nerve ‘st be preserved Postoperative treatment: The forearm should be sus pended and vascular supply checked regula. Anasto- ‘mosis ofan additional vein may be indicated if venous 5.2.40 far anatomic vrlanf atrial bleed upp) tothe had without communication beter theses supped by the ral an nar stees ‘The ral oar lpn eable with hi anata A preoperatie hls indeed Te eam smn {Sinptsses headlong ara thn sesso oe tery and hentia determine tere sped yeefi 21a ada res fp 1 Thelresm laps desectes to epos thee ary adits ‘Mca ve thew eed fh ac tet ‘Sat suppes the stn above » led Axial Pattern Skin Flaps The frum fap tmobile ons vase pode (al te and act i) and pled the cet on he do {Somethenand. The dro ef bod theoghthe fap {evosed which snow supple by be Uno sen the paSchema agam ofthe advanced il fap Th aon inde {Ste thera recon of atl Bad om, 1 alate ada ene 64 The Alpi placed nthe defect The ral ater ie econ Sted ug Ieposed secton of the gle Saphenous ‘in janet the displaced al aey wh am endo ie {ssamani The proce ron yn. he die tan venous dranage severe deo sas tie inthe lps sing the ft days postopera. Same ‘ses may rete ntrposing vent pre eae “The forearm psn place in the defect. The defected ‘he dna see covered witha spices sn gatMicrosurgical Free Flaps Lateral Upper Arm Flap (Figs. 2242-246) We prefer the fee fsciocataneous upper arm fap for covering lage delecs on the hand. Creating the flap ‘doesnot require changing the patient’ position during ‘the procedure Extending the donot sient he forse creates avery thin Map with 3 long vascular pedicle Indication: age skin and softtssue defects in the hnand sn reconstruction ofthe thumb, Surgical technique Fy, 246, Postoperative treatment: Heparinization, antbitcs, hourly evaluation of bid supoly tothe ap for three dys, stabllzing hand bandage; hand should be sus- pended 9.248. Anatomy othe dnor ste forthe upper ar fap » tee § on 2 Rides stoysntn 2 Secunda 652 Skin and Soft-Tissue Injuries 9.248. Schamtidagram ofthe puson of the alo latefl artery ative oer hueral nest 9 {um ral neve, and anstomode th the roel rece Sept ay 1 earer Bch oe Una earn tery 66 g.248_ posing he trl Huma etermusealar septum, the radial alt amy with Re ace veg, te he poster anebacil xtaneour nerve ote he ds presi tothe i ree 2 Beever emda gsMicrosurgical Free Flaps . \ > i, 2408-€ Lateral upper arm fap b Microzupeal anatomist ate pvonned to comet the Pincltesihenesintensebsseptnsdisecegtom le: "tel upp’ apt te ate ain anda dace ven ‘Giee pein Te doetonloes the ada colmteral fr tbe stare sulfa endsesastonest othe Seat sdacrveny athe pater saben and ea ornd frre ve A go Dos spy {immous seve Tevareuarpeacieo he scoctnenuap sures god pracy asimation ofthe Hp wea ection. iStamsced ter the aero he deep breil sry to Sensory svpy tothe ap nb esabsed ywching the (ete he ep. Postne rtachal tens ere 2 Tend a te nar pts bes 4 fede maemo beeen eo 2 elite 4 ud coated ney nd 671 The shape ofthe fap ens ensasee coverage of the ‘er pede 682 Skin and Soft-Tissue Injuries Injuries and Secondary Changes of the Fingernail Preliminary Remarks ‘often too ite attention s given to injures ote finger rail or the mallee Good surgical rsuls require precise Feconstrction af all structures. Anatomy (Fgs.247 and 248), igh 2473 and ital ong fe 2 Gapniar nymers an eas seins 1 Sagal seton crn Sct nd Loe) fig 2480-c_ Arterial sap ofthe dtl plane acording& Vol spect te crit and Lana) € Lateral apet 2 Dol eget 692 Skin and Soft issue Injuries Treatment of injuries to the Fingernail and Nail Bed slated injures tothe nail hed can be treated using 3 ‘erve block (Oberst and focal exsangeinaton Perish. {ng te issection with the ad of loupe magnifies recommended, ‘Suture materia: Fine absorbable monofilament suture ‘om atraumatic neales Should be used Figs 249 and b_Subungual hematoma 2 by ecmpee by pratima wth 3 se Drang he heats 70 ‘Treatment of a Subungual Hematoma (Fig.2.49) Primary treatment: Fig. 2.49, ‘Treatment of Cush Injuries tothe Nail Bed (Figs 250-252) ‘Surgical technique: us. 281 and 252. Note: Any primary defect ofthe nail bed should be re- constructed witha nai-bed grat eee riz 2 54). 250, rus ry tothe nat bet ly ta the cit phar par ou of eral arsaped ‘Seen the a bed ans tare edit pln 2 | .251Recantacton ofthe sl ed ‘Absorb fine ste ater on atacnot needs shod to ‘df eng para the toa, esha bees Danced to poet te atte na beInjuries and Secondary Changes of the Fingernail Figs 2522 and bing theatre stl phalanx with 3 pir ondspoting the nal be Eh taston a sping ih he pte’ com i 1 fan faaton an pt wth 2 este late ‘Treatment of Secondary Changes in the Fingernail and Nail Bed ‘Treatment ofa Split Fingemal (Figs.253 and 2.54) Cause of split fingernail Scaring nthe germinatve and sterile mati Surgical technique: Fig 254 Noe: Using his fee matrix grat often yields unsats- factory resus. v 5.25% oumetie impioment by = postoperative mall de- fg. 254are_ Reconstruction ofthe nl bed formity at ijry of heal bed She mts enacted ste damaged na Bd eploed 72. Skin and Soft. sue Injuries 1 The sana parton ofthe malted is eaced fhe geist Where rma sre ot pou sae artiste ‘navn shes the mateo rom eo in the eet ung fine suture mater ena Saumatie nde, Nallted Graft Indication: Damage or treumaticlssaf te nalbed and splifingernal, ‘Surgical technique: Figs 2.84 and 2.5, Postoperative treatment: immobilization in a Finger splin for two to teee meets, Flos. 2554 and b Nite gate 2 The nals exacted em the ge toe. Oth donr sess lee the ure gee or anaes spurte fae tat 1 th portion femal mato te deste Se eed fromthe donor ste tha sepel ns ngetal exc The pacton of ml enoved the pared to tc he ma a 7Injuries and Secondary Changes of the Fingernail ‘Treatment of Onychogryposs (Figs 256 and 257) Causes of onychogryposis: Traumatic partial amputs- tion of che dsl phat with injury to te nal bed Surgical technique: Reconstruction and reduction of the nail Bes, A one raf Is sed to reconstruct the ‘nisin distal phan, after which the sft issue ofthe Fingertip is reconstructed (Fg. 257) Postoperative management: The reconstructed distal phalanx shouldbe immobilized in a volar finger splint for two weeks, after which physical therapy 8 incicated to corect ne slight flexion deformity, 9.256, stra onpeheorypoc follwing parti amputs- ‘on ofthe 3st phialane s.2872-9 Recostnuton ofthe nil bein onychoaypo 3° The nai exacted the pala cava of the bed ‘Came by catelilyspsatng te na bea fe he ing tse 1b thesng bony sup recanted th a cortcocan (ce grat tan om the a es 3 ois ose) B74 2 Skin and Soft-Tissue Injuries ‘Af cresig the sina curva of he al be ae dering the bone galt thelr vattasve a be gare Died to asthe det Ts proces 9 wel aca Beaters bore got. erst ao ge Rp ora pay ype « 4 . 1 The gf is inetd int the pons! stip ofthe da ils ne wth | 2 it pan roi) 8 (9 Thewounds dom wth tention snes3 Microsurgery 753. Microsurgery sy General ‘With the ad of an operating microscope ine tractures «canbe highly magifed. The pimary indestions frie rosurgery of the hand include nerve grafting or epsir apd anastomosé of tiny vascular structures Microsurgery of the Peripheral Nerves Preliminary Remarks ‘Clase injuries othe peripheral nerves (motor, sensory, ‘or both) such asa contusion, hyperextension, teat, of avulsion ae frequently terest of Sune tauma andor {tacion injuries. Immediate repair isnot indeated in ‘hese cases. Te damage tothe nerve must be sessed In regular follow-up examinations and by evectroneuro- _tapiy. The ime interval between injury si neve ev sion may no exsed sic months, tense the increas Jing muscle atrophy canbe expeciedto produce lvevers- ible damage inthe target area, especialy to the motor endplates, In open injuries, the nerve can be completely or in «completly severed, Primary reconstruction ofthese in- Juries is only inceated when the extent of he compces- Sion can be really identified Nerve stumps are de- Drided and repaired with epineural or perineral sutures 5035 to minimize cerson onthe nerve Nerve alse indicated where iarger defects must be bridge. Anatomy of the Peripheral Nerves ‘A we variety of asciular stractures are discemible in the coss section ofa peripheral nerve Neves may have 4 single fascicle or 2 few fascicles, They may De ut ‘rouped polyfaccular grouped polyasleular src- ‘ues (Figs 3.1 and 32) Fg.2Sehemate eat amay diagram ‘tenes Har terete oc En oe 76 9.21 Cros Scion of a grouped muliscle pripheral 4 BienTypes of Nerve Injuries 1. Neuraprasa(swoling ofthe nerve without Walk degeneration) Nete rapidly regenerates. 2. Axonotmesi (axon i interrupted with endone and sheath structures intact) Proximal: nerve wil re- ‘enerate. Distal: Wallerian degeneration and re- {Eeneration may be expected, 3. Interruption of the axon and endoneurium with sheath Succes inact: regeneration simpatrd. 4 Interruption of the axon, endoneurium, and sheath structues with endoneural scarring where the ¢n- tinutgy'of the nerve is preserve regeneration i severely impaired 5, Neurotmesis (complete nerve division 6, Neuroma where the continuity af the nerve is pre- served (combined form). Microsurgery of the Peripheral Nerves Complete Nerve Division (Neurotmesis) Htopathologe changes in the Nerve Stumps Proximal stung Retrograde degeneration axonal ud Sings aegee'ator neuroma whee the conta ofthe eve cote ese Disa stump: Wala degeneration sinegratin of the aon) Camtegiaien a he myelin, atopages {Breskown) protean of contectoe tise. cele {Schwan eke and schwannoral bse aoptes swe generation do nt ota [End organs: Motor endsates, sensory receptors ‘Surgical Techniques rincura Sutre Indication: cleanly severed single fasccleor nerve with ew fascicles ‘Suture rechnique: Fig. 53. Figs 33nd b pico suture ‘he tev stumos af owe Io apoostn wth lose te "bed stures trough eprom Fie gps and asc Iarsvetresin the epee. 2 epmcten 773. Microsurgery Pernerl Sure Indication: Grouped multifsice nerve ‘Suture technique: Fig. 54, gn 3.42-¢_ Pearl satu 2 tuatsie nowe wth grouped fs, the einer ‘emo and tenes goups ae onan. Dan ‘nf pened unde te peting rcsete, ’ 4 Bande me ascites are rot nto appcton ni hed wth twotesonee sues (0 monotaet saute ‘Matt. Te elnariom pay estedIrv Graft “The primary onor nerve is the sural nerve: other possble donor sites inelbde the posterior interosseous, Feeialantebrachial cutaneous, and lateral antebrachial Fig. 3Seandb Exposing the fare roups ina nave defect larger thn 4m Foe 36a.andb Nerve galt 2° ceprte nee al laced to recoset ech fale (run nfcsthe ae ens re tee Microsurgery of the Peripheral Nerves Indication: Nerve defects arger than 4 em where direct, tension-fre repats n longerpossiole (35), Suture technique: Fi 36 1 the cl glug af recartrcted wth ere gas paced se tetrad bee 793 Microsurgery xampleo Herve Craft sing the Suro Nerve ‘The sural nerve is the most Frequent donor site. The advanages of using this nerve Inclue Is length and ‘minimal donor site morbidity. A circumscribed lss of Sensation will result onthe lateral edge of the Too, ‘which is genealy well tolerated ‘Anatomy’ Figs 37 and 3.8, ‘Approach: Fis.38, ‘Surgical technique: Fig 3.1, Postoperative ment: Immobilization in 2 plaster eae fort to tree woeks. This is followed by {hetapy and gehabtation. Regeneration i evaluated by ‘Checking for Tine sgn (Sensation of nging with per- tuston over the sie of the nerve). Neurophysiolegle Sodies are indicated a thiee-month intervals. Fig.27 Anatomie diagram of he course of thes neve Fg. Anatomie dorm ofthe origin fhe mada root of thesuranerve andthe media urs ctaneos nerve fromthe ‘bla neve ne pote Fossa 80Fig9_ Posie course ofthe sin eon or harvesting the fips. 3.108-€ Harvesting te sural eve ‘a nerve Thc turd nae seas sling we lcs, ad 3 ‘pacal rene sper 6 todiced The so nin Ie iEede posts the mallcka ts inprow xpse 3 Sestphee ein 813. Microsurgery witht uation appt the eal nee, ther sp- The tea ranch the sul nie ddd A oe rt pes aeance ang te ete cal he esiance of sate mayb obtained by advance De hve spp Sneath he Ene ok the nea med athe pon ena hetateal_ Tal othe ppl nc kina lve sat 0 the brant Wen 2 soe ffs eae the pasa! orate malt fhe rae th ml a fede hes neve pce nt the dep plan to min. tatons eer a ola nee er the Jeseel gt nth ius neseara pan, TS been atid sn neon rade the te aloes ‘he eve The nee tended and emo 1 sate ee ee ine oc 82Microvascular Surgery Preliminary Remarks ‘raumatially severed or crushed peripheral vascular structures a: small 05 aim a dlametr can be recon- ‘raced by microsurgery. A dvect end-to-end anasto- tosis may be made, rte se may be cebrided andthe defect bridged with asutably sized vein raft. Micosur eal end-to-end serial anastomoses are usally used to maintain the peripheral pattern of blood ow when revascularizing fee las. elnsare usually anastomosed fd to end, Veins have extremely thin vascular wal ‘This reqs repeatedly Mashing te site witha dlted heparin solution ocistend the vascular lumen and faci Hate performing the anastomosis Miccosuegcal anastomoses ae performed using atau ‘matic monofilament sure material (9-0, 10-0, 001-0) th intenruped sucues, ‘The various techniques of arterial anastomosis with {heir posible compilations are shawn in Figures 336- 3a, ‘Applications Replantation (Figs. 3.1-3.14) Successful replantation requires a well-trained enero- Surpcl team and 9 well-equipped specialize hospital finger thats not seltable for eplantaton ay be used 8 source of tissue graft foe 3 finger tobe preserved [Absolute indications: Amputations through oF prox- thal to the metacarpus, amputations ofthe thumb, at puutations in eilren a mulipe-cgi amputations. Relative indication slated long Finge: ‘The patient’ general condition, age, sx, and oeupa- tion te ype of ilar he restoration of fuction that may Be expected: and the patent atte ae impor tant conscerations in evaluating wether replantation ie indicated, ‘Transportation: The amputated part should be kept on cen sale plastic bag a a temperature of °C Note: The ischemia time (the tne from amputation to revasculaization) fora paft amputated throug or pro- imal othe meacresCncung muscaaie) may ot exceed se hours Postoperative management: A sterile hand bandage shoule. be applied. and the atm shouldbe elevated ‘aseular supply to te replanted finger shout be moni= 1g. Compete amputation of the Indee finger with ‘Sultaneos es ofthe mie fgee 1 sina phat 3 tlie agioun tint ‘ored every hour fr throedas, after which the monitor= Ing intervats may be extended, The vse of sysemlc he prinization and high-molecly-weight dextran should Beconsidered inthe presence of extensive crush wauma “Aiba are indicate. Postoperative treatment: Careful active and passive ‘mation exerts should egin on postoperative day 10 Complications: Thromlosis in the arial andlor ‘venous microvascular systems can secu, in which case prompt revlsion surgery is indicated. Other complica tions include skin nd sfe-ussue necrosis and infection. 833 Microsurgery a3: Disection of important structures on the vol peat fnger tga amped gh ore Sot purser bundles ae maha with 6-0 ronan 1 Gace ute en heh ey) 2 Donate 3 etn eget 5 Roe yt cn 5 Prin pine 9 Pamir it ef Srna py 2) 1320, cit gn sco ed cree me et ae Poa dit emt Reser, {Seas See ies HoMicrovascular Surgery fps tag. Reptaon ee beta eaten fhe posal pane ached sing ‘Sd hepsi. ‘anim pee wit nb ea 2 nate ue ton age 853. Microsurgery The dora poner recone with arabia & Mirourgkalanatamast te tw rope lar alr Sates (ed ares) {rari eomat ring apron Lena od the ds the oroper lar dg ness re ght to oppo {on Langer entire tothe neroasaas bn ae tie sate he var bn tah damage p= tion ses fe recomyeted wang ied em gs avested omit esos of the deta fen, Tess ‘stecorstuted wah an erased gra rom hes eve 1 alan pat ftw sent ley 2 oer po dane 4 oer par hey 86of the props dail dal ens (too rcontveted aries resure See venous net reece nepal Bo epee 4 Tesi sts ncn nde won eh ‘ot tenon 3p ies Sen gal 373. Microsurgery © The dra ponewoss recor with norsk Sutures fred toes) I Maopelntamstott veep amr dtl ing apron Cap ‘le poper pana de esse bowen aa tn, Lger cash ee athe nears tune ‘ure shores ever de othe undanaecs po on Vesa fe castle sing ies veh ea ‘esteem heen se he dara. The ee ‘secostrced wth an epee gat torte sel nee 3 tem erent sea ty) pe pn gta 5 pera on 36icrovascular Surgery mrs! anstnas of the prope dal digital ens (two ocoatcted mrss rege dee venous srt ese speromed. Where css errs ven aa 4 orl duntrne 9 Ine un sro nto capostion ante wounded vn % Meme stures FFs oo pole ce th en tenn sis sre ed. 373. Microsurgery Vascular Bundle Grafts (Figs.3:15-220) Indication: Insulficient vascular supply 10 a fully Surgical principle: Free microvascular transplant of 2 Functional finger with atrophy and sensation ofcoldnest vascular bundle (as described by Huss and eo-norkers) Tollowing reptantaion or severe crush injury (Figs. 3.16 with simultaneous exploration and possibe ceconstrc- and 316, Won ofthe proper digital nerves, Sear a Siam F238 Sevier ee eee ones mgr Dp Donor site ofthe Thoracodorsal Artery and Veln: "ished vascular buna (Fg, 2.20), ae an lal 4 4i ff Mya gy 9.245 Rostaumat atrophic index finger with sly im F316 Injury to the index Hager rl gl artery and paved vasa sappy roper palmar dit artery demonstrated y snleyoahy. aber relations very poor 1 connor pana dil es 2 bemoan 5 oper pa gait ep es 4 eternal ney np) 5 Spinach 88 |1ig.217_Anatomle diagram ofthe donor se ofthe thors esl artery and vel She vanedar uel died penal 2 the el of the ‘ops The ances fo the nsdn! ae Hed rout banc s tated a moe cin he “he ttl length ofthe are cle mast Be 3p. 2 fen oe 1 Tet ea he tore arr wih wo en Ws * comm ay Fig. 3.18. skn isos inthe hand for miosur ans- Pntation of the vascular bundle of te horcadorl artery raven 893. MicrosurgeryMicrovascular Surgery Free Toe Transfer (#gs. 321-332) Congenital and traumatic deformities of the hand occur Ina widevarey offorms. tee te wansfer is indicatee after all other recnstrctve procedures have proven “unsuitable for achieving the requted grasping function, Indication: Apasizof the fingers with severe hypoplasia oF loss of the thumb and one or more fong fingers (Fig 3.21), loss of al long fingers with an intact thumb. ‘nd loss al fingers necessitating multiple te tans- fen. ‘Time of operation: Surgery for congenital hand de- formes shold be performed between the ages of six fnd tvehe mont Following crush injuries that render the amputated digs unsultable for replantation, an immediate toe transfer may be performed vee indicate, Later te- onstruction algo possible Preoperative diagnostic studies: Doppler ultesound, Brterogram ofthe fot (lateral aspect) and oe hand if Saeclar structures are uneear [Anatomy ofthe donor site: Figs. 324 and 325. Approach: In the foot Figs. 3.22 and 323, n the hand Fgs3d £4,321. complete amputation of the thumb an indextinger Bin ea ofthe prouna phan ‘a mp were opting {rsh oro) ae near ofthe toe sete ‘Surgical technique Inthe foot Figs.3.27, 328, and 330; Inthe hand Figs: 331 an 2.32. Nove: sttaumaticdssectonis indicated. Ischemia ime Soule be as short as possible. The patients body {ermperatur and ambient temperature shoud be mon {ored The microvascular system of the foe is very sen tive; loca inteaoperative sminsration of papaverine indicated if spasticity ocars. Postoperative management: Cushioned stabilized hand bandage with te atm sigh elevated. A warming fotton bandage. shoule be applied snd ambient ‘emperature sould be high Vascular supply should be "reitored every hour for tree days the patient should be cortined Yo bed for one week Postoperative medication: Sjemic heparinization fand high-moleculacsweght destan should. be con ‘dened. Anibioacs ae indicated Postoperative treatmert: Careful active and passive notion exercises should begin two weeks postape tively. Intensive physical therapy” and reabitaion ‘Should follow ater four weeks. (Or 4,222. sla incon for emoing the second toe on the esa aspect of te fot 13. Microsurgery foe (sper pened rae) omyot te deep aye ofthe dorsum he ook ofthe sca toe 92Microvascular Surgery figs $262 shemati dagram of the most important vat- ms inthe couse of the fst dorsal metatarsal artery 3" pe dering tery restr to frm te fet dol lsat teeseoi, ed te cep las tery. The acuar Seppo soonest dsl meta artery = {he os fequnt vin: The der mettre arty urs watn the dol ntoueo «These dosimetry pet devoped or bent. ‘he dep olen str s wel Censope and eral Sp 19.327 Dosadtaction ofthe donor seo the second toe tr 13 wale eh ae 933. Microsurgery <— {938 Par con ote dvr se fhe Second ys. 2298 Oa osttoy oe ond mett- {o ated posible hyperentersion in the mettao ‘eaanaa ose te alr g.330- Toe removed for taser 1 Tonal ees gtr ns 940licrovascular Surgery j » ign 321 4°e Teaaplantion ofthe second te to the amp tate tmp of the st mec ncn ton schwe ng 38 trois were sate ein (putt cp ats ln ove fe eon ein ‘sgt meraanopszgea pn meses) bb Thetendona ead drainer of te second toe toned aor ples Tetra sel inero ‘Sota ihe cond te sd the fae pole Seis are cone ‘ted othe seco pac bea esr plies es, She tenon ofthe lg evar othe te ued with De ‘Rin ofthe tendon af he fone flexor ofthe han The Prop trl ere ae thr orale mi opaston ithe pope palmar dig Rane the on jpeg tom Bee ete 1H Beiaeteeee ci etiam «Peart for ning he xn edo andor mrs (eslvacs roto ae nee ng 4 hace mer ey ANG ope rents anton3. Microsurgery tener often exer theo ed wn estar crceteie thet Arica ro he dela ges ary ery he dor mata weno ede of eur anv ace fe fda ‘endtoend antares The medal calc Tine ere ted wo te sapere the ad «Softinue dour show 3 go eto nd. The rans feed woe aby oppo tothe ip ofthe mile nae:Microvascular Surgery Figs, 332aand Managementot the donor ste aftertranser Sk cra wth goed eposton of the get toe an thi ‘tthe second toe tee very prtinal resection ofthe second metatactl bane pe formed to som spoon sf tw fet ng the ms ‘eohsnged i Sabatan af he tanner eta ‘fehmay be ached yautaring te dep trasvse meat Saliganens Dee nese metal ianen 973. Microsurgery Pollicization (Figs.2.33-335) Pollcication refers to replacing the missing thumb by transposing along finger or par af one (especialy the index finger) on its neurovasule pedicle ‘The missing thumb can be congenital plasi) or the re sult of trauma. Where the index finger is intact, pic ation isa method that inated especially to correct ® congenital deformity (Buel-Grameto} Where the MCP oF CMC joint i intact a microvascular raft obtained ftom part ofthe distal phalane of the reat te can be used as 2 replacement forthe thamd (Mocrso’s wrap-around. method) Coricocancllout graft harvested fom the la eest must sso be inter= Dosed, Reconstruction af the joint il noe be possbie, Indications: Aplasa ofthe thumb, hypoplasia of the thumb (grade I, partial aplasia ofthe fis metacarpal and shortening af the proximal and distal phalanges 3nd Severely impaired function; grade Iv lating thumb grade ¥, four-finger and), and complete oss of the thumb, ‘Approach: Glau’ incision (Fig. 3.34) is used. Buck- Gramclo's mexified version Invoves 3 raia-palna, Shallow 5-haped incision. ‘Surgical technique: This is shown fr grade I congeni- tal hypoplasia of the hum (Fig 338)° Postoperative management: The arm shouldbe placed ina long arm thumb spea for tvee weeks, after which Specialize! active ad passive motion exercises and te- hubiliation should begin. A night-time splint should be sed for an additional three weeks . » Figs 3342-€ blots cons fr plication 98 Fig.333_typoplasn ofthe that aioe % | ! tgh. 2350. Paeation 1 tutaneos pe se raved the dos poner, dsl Sgt {olen he pervor tenn ner a xs. Hy pine thumbe lack ay tendon sects, Teo exter Fanon th dex ger oe ly ded prone tothe escapophsimgea ew tere te an the Joel Sponeoose thant ote ones nesses shor rede corepond tothe recon ofthe second eta Ste sutres tgeter Tbe teaon he tersoe aig inetnder ngs als shortened od hed tothe ba he Ferme rol pine gs 335d and 335, coral Doral ea ene Sorte 1 merece conecon 1 crewing the ceo fap The vss ofthe typo ‘hombre cowie etd. and ce Me enero ob haan painorogin neve o he mabe gers pa 3 ‘ong! poets ebtan te necesey nerve ath forthe parsed poston Supe pa 2 mn pa een 3 Sule fee ee ¢ Rrra 2 Caps pl itl ate3. Microsurgery «fost ote pels thamb. Te terns etn of the dal and palmar nesses mus ot ud ‘ret eiseted. Soper! mebizason of the second taal one peared pir to prt eseton (oe adie preneedabd the ea ip of the doa apne 100 ‘A puta vesectie ofthe sand acral spertonmed Spang the rtaczpoptngel amt ta il te ss ‘helunckonafthe poets nthe posed le. gee dep wertee metal gare ded. the Poor tears are scene he eure th Stent mcr iene 1 Tenn the eter dtrMicrovascular Surgery (eThe hes ofthe seer metacarpal sad wth aonb {orl stars in oni yperenteson 70™A0) 0 {od ypeentnson deformity Inte reveted. Gorton in wht ma gia) the pat sue kth heads ow eae proxy. 1 nn of he feeding nd inn 2} sceeriiensi bh The ebondindetingeris shanti the nen postion um sista erate O16" Per sco: 40" aa bon 20" 1 tered of tat metaphase aed oe cpl fagon the tenors ae cone ‘eta esl inten jad ie alte sp of ‘he dori poneuross (cer oc be) ‘het paar intosen oad te ue ate stot tie cal poner (acuta). “Teena ne ened to he cent ip ofthe dasa “ponerse estanor pees og.) Theesonar tone! thetndex geispne the base ofthe seen pra lane deo alles on 5 fens od pone 5 Retna te emer oe & Meacaptmedo 1013. Microsurgery 102Surgical Techniques ‘Arterial Ent nstomose or Siler Sie Wesel: Fig 336 b GA gh. 2364-8 Arterial endo anastomeri ofr ie Theta ofthe stay sus ar tue expt the poor a wae ee boc wat che then ced wih erupted th escurstmps ae debiled ange adeno renaweé, ts {mented tue ae pce 20 spat nthe bak all fe opel The tle ae let long toot asta SRE. amoung tere ster lt expose the bac alt otros 12.3, nd 4 ar gested, ad the anata. Alocepsis carl abanced wo the vcr anen fp ‘alte wh erp ses ‘dete nee «Carpeted aston 16 Grderefnte pcoet 1033. Microsurgery ArteiolEnd-ondAnostomess fr isi Sice Vessels ‘Where there are slight differences in the sizeof the ‘mina, one can attempt to date the end of the smaller vessel to match the large" one, Larger cifferences lumen size can be overcome By obliquely incising the end ofthe smaller vascular samp (Fig 3.37) 23 Te sale vascular tmp obgualy ced to match the leper one 1 the anstrasis s completed with tart ste, The eco cater fst spre 104Microvascular Surgery ‘Arter End to Se Anastomosis in ltl Artore: fie 338 ys 338d Arterial entre natomons bb Asay nur laced tert scents ha bee ered Tr te lared ans tomo ite, stn ofthe poopie se ace nthe ‘Sit wath ase sept le beste vee, ths Sn cay tel arate oy te etroped tie re fst laced on he pooty acd Competed anasto ‘be bck wala the ocr anen Ts poet Pour ofthe patos forth ret fh precede 1053. Microsurgery ‘Arter Ende Anasomoss in Arteries with trios schrte Changes Fg. 339 Complications: Thrombosis at the anastomosis site Therapy: Fg 3.40. ig.338 Atrial end-tose anastomosis arteries wth (rerindote canges [parton othe steal wal ieee ith eos to eat an pein forte anasto whteseconverel Me snatome SBleaated azar tothe posse shown figs 2.388 Figs 3.40a-d_ Management of homboss a he anastomeds 2 he ara fw terpteeywtclcamp lcd net sie of the atom ste, en the aston 3 ‘pore 106Microvascular Surgery {With he var clags tin place the te i used ih hpi ss (ied 16) vere eve fe é 4 4 Th atte ow is temparanity eapened by eesng be oval dao Th san she the kman a pers be {Eigen ey ooo! arteal flow. The parily opens nate then ove 1073. Microsurgery re Interposed ei rots Whete the extent ofthe defect ceners direct arterial anastomosis unfeasible, a vein graft must be interposed to restore vascular supply. Te fetr sie ofthe forearm 'Sespecilly well suited as adonor site Prior tothe enas. Lorna, the graft shoul e Mashed witha jet of heparin ‘soltion (thinned 1:40). Vasculrlamps are tien paced {0 occlude the arterial blood Now while creating the anastomosis, aa 341 tterposed vin raft Ineo. en ated with the vn aes ged in (ecto! Ba ow ‘Once the proximal anastomesis is complete, the ateial ‘oe fo s bry reopened andthe vein gat aligned in the proper psitin. Another vascular clamp is then placed to fellate creating the distal anastomosis (Fen), Complications can occur trom improper alignment of the venous valves ifthe interposed grafts placed inthe ‘wrong direction Fg 342). rom placing the interposed woingrattsoas allow excessive mobility (Fig 543) oF tom twisting ofthe interposee vein sat (Fig 3.48) ed 9.342 complations resulting from improper ve align: ent ofthe interposed in grt The veto vahes ht eHow lad though he tay VOMicrovascular Surgery Figg 2.422 an Complications resulting rom pling the o- terpored ve tft soot allo excess mebity ssiey cb epad vein ge 8 Wen ater od Tow 5 reopened the need sa ‘pressure dines ad nga the ierponed vein al “Tit cance he gf kan prayer ty erp the How flog eh the ae Fig 348 completions eesuting rom twisting ofthe inte posed vlog Fetal orton erpatment of Bood fw 1094 Compression Neuropathies mM4 Compression Neuropathies General ‘Compression neuropathies can be the result of trauma br continuous compression along the course of peri fal nerves de i variety of causes including fens hovitis, bematoma, rumors, nd muscular ad vascular anomalies. The dajnosis is made on the basis of cca ‘symptoms, supported by electromyography (EMG) and evaluation of nerve conduction velocity. Occasionally, Uluasound, Cr and MR suds are also required Compression Neuropathy of the Preliminary Remarks Five sites along the median nerve are prone to compres- son neuropathies 12 ‘Therapy consists of decompression ofthe affected pe ripheral nerve and eplneuroyss where indieate, This chapter shows te anatomic courses, areas of motor and sensory supply, aid most common entrapment ses Ofte median, ena and vada nerves, Median Nerve Anatomy (Fes.42-46) Function (Fig 47, see also Fig 418) linical Picture ‘© Los offevion nthe thu. index finger, and mide finger due to paayss of the following musces: Meir poles longus (anterior inerosseous nerve), fletor digitorum superficial of the fingers, exor {igitonum prfundss of the index and mile fingers {anterior iteossesus nerve}, superfcta head ofthe Nexor polis brevis abactor poli revs and op- ponens pals. + Tena opty wm weakened opposition sn a- ig Posstle ntopmentsiter lng the course fhe me ‘Ban neve 1 ersten { Societe ESSE RI EE yn o Rg cuegreeeemrter ee © Cap inl romero mh al aeCompression Neuropathy of the Median Nerve 1134 Compression Neuropathies Fo. Diagram of the muscle he hon supe by the megan nese gh 50-¢ Most frequent anatomic variant the rain of i the moter bane ofthe median nerve 1 nen fe tng gs | 14‘Compression Neuropathy of the Median Nerve . ’ ign 46aand_Catanousinnertiony the medin nerve Dosim 1 per i ales 1 foe acne gta etl ene 3 ara mean ene gy 47aand b cette fit be ipatos offuntn ad api tha wih igh Sharma entian not the madan new 154 Compression Neuropathies Compression of the Median Nerve at the Ligament of Struthers (4 in Fig 4.1) Approach: Fig. 4.8. ‘Anatomy and course: Figs. 49-411. ‘Surgical technique: The median nerve is decompressed by releasing the gament of Struthers ie. an Fig.68 Shininesion teapot median nerve atthe sow \ 5 Neda Fig.29_ The medan nerve ic xpotd inthe repon of the me- mera ttermuscuar septa to eal pa of etty int the pronstor tres, 16Compression Neuropathy of the Median Nerve Fig.410. Powe entrapment ofthe madan nerve where H.411_ High exign of the haar head of the pronstor pases trough the medial hima Itermurculr septum interes inthe presen of 2 upraconl proces fhepeeumce of 2 supraondyae process (igament of Struthers in 9.4) 1 apart oe 4 spon ees 3 Medan 2 pine Svmer neon Be apr ee the tons athe mad ona oper) 174 Compression Neuropathies Compression of the Median Nerve at tthe Bicipital Aponeurosis (0 in 41) Approach: Fig 48. Anatomy and course: Fig. 4.12. ‘Surgical technique: The median nevve f decompressed by eivding the Biciptalaponeurosis (Fg. 413) Fig12 course ofthe median nerve athe level of th bp ‘alone 118Compression Neuropathy of the Median Nerve Fig.429 the median ere xpoted ‘er dviston and reaction af the bet! sponcrons antecubital ons 1 Bean nm ne (tates 1194 Compression Neuropathies Pronator Syndrome: Compression of the Median Nerve by the Pronator Teres Muscle (cin ig.1) Clinica symptoms: Pain on the flexor sie ofthe fore- arm, sensory diets on te radial aspect af he thumb lane is ere Fnges, total or paral loss of Nexon in the proximal interphalangeal Joint of the thumb, Palen’ sign s negative (ost lle symproms by Nox: Ing the wns). ‘Approach: Fig. 48 Anatomy and course: Fig. 4:14 Surgical technique: the median nerves decompressed by pesforming aascocomy inthe region ofthe pronator (eres. In are cases, the muscle must be dlsecte ois origin Postoperative management: The elbow s immobilized In medium flexion for one week, after which peysical ‘erapy begins ig are. Vins of he course of the median mere in the elon of he ponstor tres. "ire cores toca the hertalangUnarhess ofthe po- by Nene eauos haves the haar of the promises Mere Berea the pronstor eesCompression Neuropathy of the Median Nerve Anterior Interosseous Nerve Syndrome: ‘Compression of the Median Nerve by the Arch Forming the Origin of the Flexor Digitorum Superficialis, (DinFe.an) ‘tinct symptoms: Pain in the proximal forearm, par= {ator tora fossa function in the ex ditorum pro- Findus afte thumb and index ger, exor pollicis un and prontor quadrtus. There sno sensory less. Anatomy and couse: Fig 418 Surgial technique: Fig. 4.16. Postoperative management: The arm is immobilized forten dys na fongarm plaster cat with the wristina ‘etal postin, the foreasm pronated 45% and the low Nexed 45 Physical therapy for te elbow begins fe week postoperative, F435 Madan nerve branchor ln te deep planes atthe ‘bow 1 Tendo acho te gna ta Stone (Guicicofcomprto a he neo neve es te 121Fig416 the tendinus arch ofthe oii ofthe fer di torum superiors nce to deconpart the medion ee ans ta) on 122Compression Neuropatiy of the Median Nerve Carpal Tunnel Syndrome: Compression of the Median Nerve in the Carpal Tunnel (ein Fig. 41) nical symptoms: Night pain in wrist and distal fore= arm at rest, sensory dees inthe fingers supplied by the median nerve, and loss” Tine motor function (aenar atrophy). hale’ sign Is postive tet tilt symptoms by lening the wrist. Function: Fig. 4.17 lineal picture: Thenar atopy due ro pass of the superficial head of the abductor polis revi op ‘Ponens polis. and se and Second lumbrials (hardly ‘decetable in ciel examination), There i los of se sation in the region supplied by the median nerve distal (0 the carpal rane ‘Approach: Fig 4.18. ‘Surgical technique ig, 4.19, Note: The flesor retinaculum is usually not recon- structed. A Z-plasty closure ofthe retinaculum may be ‘considered for young patents in vans! cecupations. ostream of he hum and te inger 1 ypc af fncton and atopy wth compression of the esan tenet all pan ee a Alternatively he Nexor retinaculum may be divided en oscopicaly. Closure: The wound i closed in a single layer. Nonad- Sorbable maonoflasent sutire (4-0 or 5-0) 1s use, Postoperative management: The wrist i immobilized for ten days ina stalizing bandage or dorsal psster Complications: These include damage to the thenar branehof the median nerve (Fg 419), damage tothe palmar branch of the median nerve, and recent Sympions. 1234 Compression Neuropathies Cates bee noe a cpr he mean neve carpal tne yo {a 4300-4 agree med ne capt ‘ein "hx por pores inc andthenprton of the Isarrenaculomis cde oan tat thethena ban 3 BegaCompression Neuropathy of the Median Nerve & ‘> The capul tunel is opened a the mada rare wth smatoran emo branches ose 2 sgt ao en 2 Nes tte tag apes 5 trv ran 5 Menino gor oat «© The orm hc dvd substan 2 pi or smato the enropmert te The ylar branch a the mean ane presaned. Osco Wal be pecs deat res Be eso ranch fhe mean seve 1 Rome tina iad) 2 Nr an of ma ee 4 rina bar fe mada ere its of he median nerve athe erbapret Se 1254 Compression Neuropathies Ulnar Nerve Compression Syndromes Preliminary Remarks ‘Three sites along the ulnar nerve ae prone to compres- sion neuropathies (Fg. 420, Anatomy (rigs 421-425) Function (rs.426) 126 nical Picture {© Pronounced yyerextension in the metacsepo phalangel joints of the rng gee and lite finger. ‘Theres ossof function inthe Interosseous muscles and the third ane fourth Tumbrcals © Moverate hypesaxtension in the metacsepo- pllangeal joints of ce index finger and mide n= et, There Is los of funetion in the interosseous ‘uscles but there no les of funtion in the second 8nd curd lumbei, which are supplied by the me tian nerve «# Thering Finger and sina finger ace abducted Loss of fusetion in the interessl resis in unt deviation caused by the unchecked action ofthe extensor dig Hypereatenson in te metacarpophalangeal ont of the thumb, Theres loss of fonction in te deep ead ofthe Axor pals brevis. © Te fingers cannot be spread: thereis oss of function inthe palmar an dorsal interosse 4 The pinching vip between thumb and index finger is is loss of function in the adctor © Avopy ofthe fist interdigial space is seen. Func tion's replaced by the flexor pollicis longus supplied by the median neve) ‘» Froment' sign is sitive (pronounced flexion in the Imerphalangeal jie dug exercise} ‘slated flexion ofthe distal phalan of the smal fin- gets nt possibledue to ass ofeton ofthe fourth 8nd filth Resor digterum proueus. | | | | | | | | |Ulnar Nerve Compression Syndromes 2.820 foe epment ste ong he reo 4 nmin ete an fn aba st! were ampn in apt at Fie-621- Schematic dag ofthe course ofthe lar nerve 1274 Compression Neuropathies 428, Sehamatc gram of the potential conection be: teen the motor rch of the ulnar eve an the eceret branch of the mc neve esrb by Cannievche 1 cape nr ee 2 ter benn o teure 3 Spent eons 5 rma ach ofthe man nee ith te dn ee ig.22. Schematic dapram of the musi of the fore Fig. 4.24. Schematic agra of Caye's anal [iivand hand spied by he uno ete 1 Marat pt oe) oper pa a es 3 Sha eove 128Ulnar Nerve Compression Syndromes . » Figg 420 and. ataneous fneration by the atar nerve 2 far ache 5 oral bah learn . > gg. 4263 and b_ Hand in nea postion 2 Na neton B Totti function othe hand wah esion fhe ae ree (ew hr ear) 7294 Compression Neuropathies ‘Compression of the Ulnar Nerve at the Elbow (a snd in Hg. 420) Surgical Treatment Options ‘After decompression the ulnar neve can be replaced in the tunnel. This is done when compression is due roa tumor ‘© Subcutaneous transposition ‘© Submmuscular of intramuscular transposition ‘Resection of the meal epiondye (indicated in the presence of artritechanges in the elbow) Subcutaneous Tonspestion Approach: i. 427 Surgical technique: Fig, 28. Postoperative management: The wrist is immobilized ina mide pesto for ten days ina stablizing bandege or dorsal plaster ease Motion therapy and electrother= apy beain three aceks.posineratvey. Electromyo- fraphic follow-up studies (EMG) ate abtained three ‘months postoperatively 327 km neon i cubital tunel syndrome 1 Med ane ecane 130op 4280-4 Decompression of the war nerve i eubital tunel syndrome 2h ee xan ey vr et Ulnar Nerve Compression Syndromes 1 etl ac ofthe ails cana rene 3 he enone 4 Sonatas te nes 1 dlrs sen 1 subautneous antrorvansposton ofthe br pre, The enemas acho corel ana me ed The ‘wo muscles re thn crily nope > pert Spang nasa ep at tot ‘enon tered expe tava jut tthe hee. fae of Shuts died prsialy and he mec Me Fase spur esata 1314 Compression Neuropathies anda Aer stetaeos apn ses ped shot tanto te can thane 2 edleiare tansy wong) 5 rae abe 4 Aer neon te 132Ulnar Nerve Compression Syndromes Compression of the Ulnar Nerve in the approaches: Fg. 428, ‘Wrist (Guyon’s Canal) (cin i420) ‘Anatomy: Fg 430, ser ls Fi. 24 Surgical technique: Fs. 431 and 432 Postoperative managerent: The wis is immobilized forten daysin s dorsal plaster st Motion therapy and ‘ectthorapy begin the weeks postoperatively. le tomographic flowy studies (EMG) are obuained fhrce months postoperatively. Quy Ae \ { 7 . , seat Sn meee re apse syst es Seton pine pte ae 4 Ral bury hea ec, ar margin the pur 5 oct buy a min oa ee4 Compression Neuropathi 2 The oor pene exposed Gaye's aa Fc fu oan Tenn of i coy 1 ert ett eae 18 eaten the sci te rca died 1 expose te enrapnart ‘Se tthe vel the prone! Dey, 1 pel hans aoe 3 recta fig,432 Decomprasion ofthe ae neve in Gayo anal The ls ere eased reveals gangn eompening the es) ban thar ere the the eat boy 2 Gedion 134Radial Nerve Compression Syndromes Preliminary Remarks Four sites along the cadial nerve are prone to compres- slon neuropathies (Fig 433). Anatomy (figs.4.34-4.36) Function (ris.237) Clinical Picture ‘Inability to extend te writ in radial deviation (loss ‘of function in the extensor capi lars, extensor ‘acpi radials longus, and. extensor carpi radials brews ‘+ Inabil o extend the finger (lass of funtion in the ‘extensor digtorum and the extensor indi), ‘+ Inability to extend or abduct the tum (loss of fanc- tion inthe extensor polls longs, extensor polis brews, and abductor pollicis longus), fj28 foe etopeen ite sog the cue fe etna tke Rivera naneton ‘SS mee mre aes 1354 Compression Neuropathies 5g.438 Schomti agra ofthe course of he real neve toes ee ; Sten rate Zeros Bee 36 Fig,435_ Motor inmrvation by heal nerve 1 gett oe Sr Serene iS ieee PEE natmtmmtprm tect Bepahmaeteatamerer tse 3 oer i eect i emcee i eaaie SeemsR Nerve Compression Syndromes Fip.436 cutaneous inervatin by the eda narve Spl anh the al ene ed ns Fig. 427aandb union ofthehandin extesanofhe fib yp yhoo nthe hand wth a praia igh) eon of oes ‘eral rvs fp vit deter amore dtl lesen 3 Norms function the impaent othe con ote tenon ay ding on hee ol ws B374 Compression Neuropathies Compression of the Radial Nerve at its Point of Entry into the Lateral Humeral Intermuscular Septum (Ais Fe.433) Approaches: ig. 438. Surgical technique: Fi. 438. 438 Decompresion of the rail neeve a 8 paint of ‘enty It the tral humeral terms sept and he SRpintor ome! (in fig #53 se Bing 83) Tera new expe ad th el etl area 1 Set ht ene 3 cha teu (sae) 138 Eero, 3 EEE cIS Eat Thy ateanen * eiteminsRadial Nerve Compression Syndromes Posterior Interosseous Nerve ‘Syndrome: Compression of the Deep Branch of the Radial Nerve at its Point of Entry into or Exit from the Supina- tor Tunnel (01 and 62 in Fig. 433) ‘Approaches: Fig. 4.38 and 440 Anatomy: Figs 441 and 442, Surgical technique: Fix 438, 9,440 Dorsal kin incin fran erm approach tthe ‘aia mere the supiatr tel 9.441 Schematc lagram othe course ofthe deep branch ofthe ada ere trough the spinator tre! 2 rp ban of tad nae Petocicneioy 5 eof ete poet wey a a ne neti 1394 Compression Neuropathies ig.442 the rail nevis exposed i the spinor tunnel lncean the enters cri radi Breve nd the extensor aigtoran 2 Pasar mos 1 ier ote 140Radial Nerve Compression Syndromes Wartenberg’s Syndrome: Compression of the Superficial Branch of the Radial Nerve at the Point where it Penetrates Fascia of the Forearm (cin Fis.443) Anatomy: Fig. 443, see als Fg. 128, Surgical technique: Fig. 4.44, 9,443 Anatom gram of the superficial branch of he ‘nerve ats pol of nyt the fora asa 2 Sper rach of dal ve 4 Rolie palo te rere he 7 9.448 Oecompresion of the supertal branch ofthe ‘a ere st point of entry into te fi of the rears eteun the brachorale apd tenor carl els angus Pati eeon ote ea ac. 1 Poet ony te peal tae ea nee 3 wn ace py ie) 1 Sipe Se of hal ne 3 Glaerenpadah tome 1415 Tendon Transfers 1435 Tendon Transfers General If satistacory function does not occu after microsurgi- ‘al reconstuction or decompression of peripheral nerves, pecforming tendon tanslers may significantly Improve or restore compromised oe abyent hand Tunc- Optimum results depend on selecting the proper muscle tendon unit tO. tansy, achieving. the. sralghtest possible cretion of pull, anon the proper initial ten- Slon in the muscle, Stabilizing procedures such as ar- thodesis and tenodests mist be considered in planning the transfer, Indications: Congenital deformities, muscle desiruc- ‘on ad tendon injuries, 144Median Nerve Palsy Function (see Fg 570) Clinical Picture ‘Loss of exon inthe dumb index finger, and middle Finger due to paralysis of the following. muscles: flexor polis longus (anterior interosseous neve}, Nexor digitorum superticais of the fingers, Nexo? dittorum profi ofthe nex and mle fngers (terior imerosseous nerve) superficial head ofthe fexor poles brevis, abductor polics brevis, and op ponens polis ‘+ Thenar atrophy with reduced opposition and abduc- tion Proximal Median Nerve Palsy ‘Surgical Principle ‘© Flexion inthe index nd mide ger is restored by ‘suturing the lxor digitorum profundus tendons of the ring inger andl finger to the flexor digitorum, profundus tendons ofthe index and miele tinge. ‘Flexion inthe thumb is restored by suturing the ten- ‘dono the achoracals wi the Hexor paths ln {us tendon ‘+ Opposition i restore inthe thumb by transferring ‘one ofthe tendons ofthe extensor indi, extensor ight minimisextensorearpiradilis longus, or exten- Sor expt wats Distal Median Nerve Palsy ‘Surgical Principle ‘+ Opposition (opponens, abductor pollicis brevis, and stiperficial head of the flexor pollicis brevis) i re ‘Stored by tendon transfers to replace the opponens polis Abdur Digit Nini Ter (Figs. 51 ae 52) Preliminary remarks: The abt digit minim ap an also be raised asa myocutaneous sland fp to im prove the thenar coniout Indication: injury tothe median nerve and prima in congenital hand deformities. Approach Fig. 5.1 ‘Surgical technique: Fig 52 ‘management: The hand is immobilized ‘eth the writin sigh exion and palmar abduction for three weeksin a dorsal plaster forearm cast After hist is maintained in a removable nighttime spine for nates four weeks and ate and passive motion excr- ‘ses can begin Fig9shinincons oan abductor ig i transfert replace the eponens pis 145,5 Tendon Transfers Fig. 2a-t Abdutordigt minim tasertoreplaethegp- The suc clgt minis dived a ito mati {ed roumay Cae stan to peeve WS eure 0h 2 peed mit 146Median Nerve Palsy The apis ected to rset mobaed bc gt tn on ts pele. om nkenta preserve Sauron es 1 oes bao earn 3 oes « 4 Gtr ch ft on eve 4 Thesbeucor dt mint tafe btanecny othe reaarpoptlangel orto he hub ‘ 1 mdr at mere 1475 Tendon Transfers 1 Once the scans ase as en competed the - The dé terns si of the abductor Ba iin ‘ons the spar dt moi fede lange. | ued te tenors te etensr oles longus ana abd ay {or pales bes tthe metscapephalnges Jot ofthe ono il 2 felnetcn oa 148Median Nerve Palsy ofthe Fer Dita Superfasofthe ing Fin or ges.) Indication: Injury 0 the median nerve Approach: kin incision athe level ofthe distal palmar Figs. 54-57, see also Figs 5.13 ‘The Nexor digitorum superfialis ofthe rng finger i = cated and dvided between the AI and 2 pulleys. the Tengeh of the tendon is not sufcent, ics separated farther cstal at the level of the proximal phalanx tough a mediolateral shin incision. ‘Complications with removal can include a flexion con- tracturein the presimalintesphalangea joint or aswan- neck deformity (8% ofall cases) Possible technigues for redirecting the tendon: Fig. 5 Possible techniques for reinserting the tendon of the flexor digitorum superficials of the rng finger atthe ‘metacarpophalangea inc of te thumb include Brand's ‘method (Fig55) Bunnel and Royle Thompsons ‘netliod (ig. 56) and Rlorda’s method (ig.5.7) Fig. 52 Schematic diagram ofthe tendons of the exo dig {ovum sper he agers andthe tendons of the er eaplunens 1 Teo he fs datonm gril hen foe 4 Trlonst ne nro 1495 Tendon Transfers Sosa anette enna tet diana Talend won pss eet dol eee [eels ofthe sng tnger to replace the oppanens pls Crp sas Shemale gram aera deere forum pees the rng ngeorepocete opanenspom 1 Teck ote en ci us 2 Tan athe we tum spat en ner oe tx eg he eon 2 ossstomecusing mallet dtl parton ths eagonak peeled window is pene it the ona etna 2 Ten he er pam pert hci ger_ 150ee _::. _QSeeS_ ae Median Nerve Palsy Figs 55a andb The tendon ofthe flexor digitorum spes- bal pect (his of the ing finger incensed a the. Meta Sophalnge jo of he tam 1 eof er Son pao ng ge Eis mete 2 iicicor pee eo Grip denon fhe agen pac hne 3 Swe an fing figs pase tough he tendon of the sac paca £ AEGIS: pace (tir tnd end the tncon ft emenar pac ons and 5 Tendon afte cenn lke nc ey 4 Tendon ae enol ws The second sp swapped around the sur posal to the intacrpstligea abt deci ancored tothe te ‘deus rerion ee attr plesand the este a the Ist f the prnmal pao fe thd 2 ar pec eee Ee aces See tte a am neton ie Sooe ieee 1515 Tendon Transfers 58a and B_the tondon ofthe flare dgtorum super fale of the tig finger rinsed atthe metacapo- Phslngel en ofthe thu ane nd foeTuoresors method Dar lp of the ene irom sper tendon passed ‘rough esd he et mtacag nd wtre eed Sp dal to the metcpophaanged Jon oer the dtl ponerse. 2 rapt “et eto te pti noe SS (vr te Seon En 152 . ada sree lent Sr term ser fhe tne Tenn cepts brsMedian Nerve Palsy Figs 572 and ® the tendon ofthe les cgtorum supe fils of the rng finger rserted at the meta Drange! ofthe thu Redan mecod| ‘Gres sucha the feo Sonam supercleedon i pased ‘tough tne tan ofthe actor polis ren an he ein 3 the ese oles ones 1 elon har dun ipa he iy gs 2 Fl pt te 3 Tether ae 5 Sxprent pace 5 nn he bcp rg b 1 enn ft Sn atari perc oe 2 Ooo peer 3 fdr es ous 4 acral 5 Neon he amr ote gue i eon the amor gta bee 1535 Tendon Transfers Ulnar Nerve Palsy Function (see Fig 5268) Clinical Picture ‘+ treme hyperextension of the metacarpophalangeat joints in he ing finger and smal finger wit ass of fusetion inthe interest and the hrc of the middle and ting fingers Moderate typerestension of the _metacar- Dophalangeal Joints in the index finger and middle finger with fss of function in the Interoseous smucles. The lumbrcals of the index and mide in {ets remain functional (supplied by the median nerve ‘6 Abduction of the ing fnger and small finger Loss of function in the iterose results in ulnar devietion de to the action of the extensor digitorum. ‘+ Hyperextension ofthe metacarpophalangeal joint of ‘he thumb with los of function inthe deep ead of the Mexor pallies brevis ‘© The ingers cannot be spayed Theres lss of func- tenia the palmar and dora interosse, ‘+ The thumb to index tip pinch s weak with toss of function inthe adductor pollicis and visible attphy inthe fist interdigital space. Replacement: flexor Dalles longus (supplied by the median nerve. Fro- ments sgn is poste; there i strong Mexion inthe Inerphaangeal joint during exercise. ‘The patent is unable to fex oly the distal phalanx of the itl finger due t loss of function in the Mexor igiterum profundus of che cng and ive fingers. ‘This only occurs in proximal ulnar nerve palsy Proximal Ulnar Nerve Palsy ‘An una caw hand deformity of the cing finger and sinll finger is present (this sa mild frm because the flexor aigtorum profundus of the ving a lle fingers are also paralyzed). The pinch mechanism is also ‘weakened, Distal Ulnar Nerve Palsy A severe ulnar caw hand deformity ofthe ting flager and smal finger i present, and the pinch mechanisi is weakened, Surgical Principle ‘+The claw hand ard the hyperextension inthe meta gh. 650, & Altachinent of am anusion of the extensor Sponearose wih» sll exsocrtoginous agin hlved wth a pull vie ‘tm tee le eng the dtl phan, nthe wes {chord pehery ora aston ard sea wher by presig aiieteler ney ater nrwanyovane 2 Pec reaped son tarExtensor Tendon Injuries .6260-¢ Aachment of an avon of the extensor energies rage th © alone Fracture Dislocation of the Distal Interphalangeat Join, ype W (eis.027 and 6.28) «Pin stabilization with retrograde drilling technique rn Stblzoion with Retrograde Dlling Tecgue (ig.628) Ingication: Palmar facture dsication with instability (ofthe dtl otephalanges joint cue to avulsion of & lige dor per aly retest le ticular surface Approach: Z-shaped incision over the distal iter Phalangea joint. Surgical technique: & double-ended pin Is inserted through the surface ofthe acture atthe Cener. The dil \ \\ WN 0,627. almar facts action with tality of the (tl interphalangeal one due To lion Of age Beat Fregment (ype 1 en te te datum ond 3 hte eras igiest ‘en range bole cid rou te base of he da Dain andthe auhed aga een Be wre es En ln acre or moos. The deal iteraage oe ‘iy Sue be eased steon depending on ve sbiy hired ith the Sut fs moved and the end ofthe pin is driven into the distal ‘Phalanx. The cstalIntephalargea join and fragment Se reduced by applying palmar and dorsal compression ‘with the joie etendee- Te pin s driven Back tough the fxgment and the dal phalans Pin: Double-ended pin 1-12 mmin diameter depending ‘onthe sizeof the faaent Postoperative management: The stm is immobilized for four weeks ina palat ast and Mager split. after ‘which the pin Is removed. radiographic exemination {ssi con bone ge pin Stemored and she finger is further immobilized na eustom finger spe 2s In gonservative treatment for another week or two (see pri94 and Fig, 622, yi Fie.62%a-t Retrograde ling techni suse npn stab Toton af patrar acre location with sabi ofthe ‘Seal ieerpalongeal jot due to lion of ge oral 1 'Uoubie ended inetd rough he ace of the fa Surat the bn of te ota pane 197