Techniques in Orthopaedic Surgery The Hand 3rd Edition 3nbsped

Editors
Steven D. Maschke MD
Hand and Upper Extremity Surgery
Department of Orthopaedic Surgery
Cleveland Clinic
Cleveland, Ohio
Thomas J. Graham MD
Chief Innovation Officer
Justice Family Chair in Medical Innovations
Vice Chair
Cleveland Clinic
Cleveland, Ohio
Peter J. Evans MD, PhD

Director
Upper Extremity Center
Cleveland Combined Hand Fellowship
and Peripheral Nerve Center
Cleveland Clinic
Cleveland, Ohio
Contributors
Joshua M. Abzug, MD
Assistant Professor, Director
Pediatric Orthopaedics
Department of Orthopaedics
University of Maryland School of Medicine
Deputy Surgeon-in-Chief
University of Maryland Children's Hospital
Baltimore, Maryland
Ngozi Mogekwu Akabudike, MD

Assistant Professor of Orthopaedic Surgery
University of Maryland School of Medicine
Attending Surgeon
University of Maryland Medical Center
Baltimore, Maryland
Donald S. Bae, MD
Associate Professor of Orthopaedic Surgery
Harvard Medical School
Attending Physician
Boston Children's Hospital
Boston, Massachusetts
Blaine Todd Bafus, MD

Case Western Reserve University
Hand and Upper Extremity Surgeon
The MetroHealth System and Department of Veterans Affairs
Cleveland, Ohio
Mark E. Baratz, MD
Clinical Professor and Vice Chairman
University of Pittsburgh School of Medicine
Director of Hand and Upper Extremity Surgery
Community Medicine, Inc.
University of Pittsburgh Medical Center
Pittsburgh, Pennsylvania
Mark R. Belsky, MD
Clinical Professor
Tufts University School of Medicine
Hand Surgeon
Newton Wellesley Hospital
Newton, Massachusetts
Imran K. Choudhry, MD
Staff Surgeon
Orthopaedic Associates, LLC
Denver, Colorado
Michael Darowish, MD
Penn State Milton S. Hershey Medical Center
Hershey, Pennsylvania
Colleen Davis, OTR/L

Occupational Therapist
Hand Therapist
Physical Medicine and Rehabilitation
MetroHealth Medical Center
Cleveland, Ohio
Brian M. Derby, MD
Physician
Sarasota Plastic Surgery Center
Staff Physician
Department of Surgery
Sarasota Memorial Hospital
Sarasota, Florida
Peter J. Evans, MD, PhD

Director
Upper Extremity Center
Cleveland Combined Hand Fellowship and Peripheral Nerve Center
Cleveland Clinic
Cleveland, Ohio
Varun K. Gajendran, MD
Hand Surgery Fellow
Cleveland Clinic
Cleveland, Ohio
Thomas J. Graham, MD
Chief Innovation Officer
Justice Family Chair in Medical Innovations
Vice Chair
Cleveland Clinic
Cleveland, Ohio
Beatrice L. Grasu, BS, MD

Orthopaedic Surgery 4th year Resident
The Curtis National Hand Center
MedStar Union Memorial Hospital
Baltimore, Maryland
Warren C. Hammert, MD
Associate Professor of Orthopaedic and Plastic Surgery
University of Rochester Medical Center
Strong Memorial Hospital
Rochester, New York
Heather R. Harrison, MD
Clinical Fellow
Cincinnati Children's Hospital Medical Center
Cincinnati, Ohio
Mark F. Hendrickson, MD
Staff
Department of Plastic Surgery
Cleveland Clinic
Cleveland, Ohio
James P. Higgins, MD
Chief
Curtis National Hand Center
Union Memorial Hospital
Baltimore, Maryland
Harry A. Hoyen, MD
Associate Professor
Case Western Reserve University and Cleveland Combined Hand Fellowship
Chief Hand Service
Cleveland, Ohio
Helen G. Hui-Chou, MD
Hand Surgery Fellow
Division of Hand Surgery
Baltimore, Maryland
Lawrence C. Hurst, MD
Professor and Chairman
Chief
The State University of New York
Stony Brook, New York
Aaron Insel, MD
Orthopaedic Hand and Upper Extremity Fellow
Stony Brook University Hospital
Ryan D. Katz, MD
Faculty
Baltimore, Maryland
Michael W. Keith, MD
Professor
Case Western Reserve University
Director
Hand Surgery
Cleveland, Ohio
L. Andrew Koman, MD
Professor and Chair
Wake Forest School of Medicine
Wake Forest Baptist Health
Winston-Salem, North Carolina
Scott H. Kozin, MD
Chief of Staff
Shriners Hospitals for Children-Philadelphia
Clinical Professor
Temple University
Philadelphia, Pennsylvania
Donald Lalonde, BSc, MSc, MD, FRCSC

Professor
Dalhousie University
Plastic Surgeon
Saint John Regional Hospital
Saint John, New Brunswick, Canada
Gregory A. Lamaris, MD, PhD
Plastic Surgery Fellow
Department of Plastic and Reconstructive Surgery
The Cleveland Clinic Foundation
Cleveland, Ohio
Jeffrey N. Lawton, MD
Associate Professor
Chief
Hand Surgery
University of Michigan
Ann Arbor, Michigan
Matthew I. Leibman, MD
Assistant Clinical Professor
Newton Wellesley Hospital
Kevin J. Little, MD
Assistant Professor
University of Cincinnati School of Medicine
Division of Pediatric Orthopaedics
Cincinnati Children's Hospital Medical Center
Cincinnati, Ohio
Susan E. Mackinnon, MD, FRCS(C), FACS

Sydney M. Shoenberg, Jr. and Robert H. Shoenberg Professor
Chief
Division of Plastic and Reconstructive Surgery
Washington University School of Medicine
Barnes-Jewish Hospital
St. Louis, Missouri
Kevin J. Malone, MD
Assistant Professor
Case Western Reserve University School of Medicine
Hospital Staff
Cleveland, Ohio
Patrick G. Marinello, MD
Orthopaedic Resident
Cleveland Clinic Foundation
Cleveland, Ohio
Steven D. Maschke, MD
Cleveland Clinic
Cleveland, Ohio
Michael K. Matthew, MD
Assistant Professor
Lerner College of Medicine
Cleveland Clinic Staff
Cleveland Clinic
Cleveland, Ohio
Michael A. McClinton, MD
Associate Professor
Johns Hopkins Medical Institutions
Medstar Union Memorial Hospital
Department of Hand Surgery
Baltimore, Maryland
Kenneth Robert Means Jr, MD

Attending Physician and Clinical Research Director
Baltimore, Maryland
Justin B. Mirza, DO
Orthopaedic Hand and Upper Extremity Fellow
Stony Brook University Hospital
Nathan A. Monaco, MD
Resident
University of Pittsburgh Medical Center Hamot
Erie, Pennsylvania
Brian Najarian, MD
Associate Faculty
Attending Surgeon
Cape Cod Hospital
Hyannis, Massachusetts
Michael W. Neumeister, MD
Professor and Chair
Southern Illinois University School of Medicine
Springfield, Illinois
Thao P. Nguyen, MD
Resident
University of Maryland
University of Maryland Medical Center
Baltimore, Maryland
Nikhil R. Oak, MD
Resident Surgeon
University of Michigan
Ann Arbor, Michigan
Loukia K. Papatheodorou, MD, PhD

Orthopaedic Surgeon
University of Pittsburgh
Orthopaedic Specialists
Ebrahim Paryavi, MD, PhD

Scientific Research Director
Baltimore, Maryland
J. Megan M. Patterson, MD
Assistant Professor
University of North Carolina School of Medicine
Surgeon
University of North Carolina Hospitals
Chapel Hill, North Carolina
Allan E. Peljovich, MD, MPH

The Hand and Upper Extremity Center of Georgia
Atlanta Medical Center Orthopaedic Residency Program
Shepherd Center
Atlanta, Georgia
Lance A. Rettig, MD
Volunteer Clinical Assistant Professor
Indiana University School of Medicine
Indianapolis, Indiana
W. Lee Richardson, MD
Fellow
University of Rochester Medical Center
Chief
Strong Memorial Hospital
Rochester, New York
Benjamin J. Rogozinski, MD
Resident Physician
Atlanta Medical Center
Atlanta, Georgia
Jason M. Rovak, MD
Hand Surgery Associates
Denver, Colorado
David E. Ruchelsman, MD, FAAOS

Clinical Assistant Professor of Orthopaedic Surgery
Assistant Chief of Hand Surgery
Newton-Wellesley Hospital
Julie Balch Samora, MD, PhD, MPH

Clinical Hand Fellow
Brigham and Women's Hospital
Rebecca J. Saunders, PT, CHT

Clinical Specialist Research and Staff Development
Department of Hand Therapy
Medstar Union Memorial Hospital
Baltimore, Maryland
Keith A. Segalman, MD, FACS

Attending
Assistant Professor of Orthopaedics
Johns Hopkins University
Baltimore, Maryland
William H. Seitz Jr, MD

Professor of Orthopaedic Surgery
Cleveland Clinic Lerner College of Medicine of Case Western Reserve University
Chairman, Orthopaedic Surgery
Lutheran Hospital and Cleveland Clinic
Cleveland, Ohio
David B. Shapiro, MD
Orthopaedic and Rheumatologic Institute
Cleveland Clinic
Cleveland, Ohio
Mark C. Shreve, MD
Hand and Upper Extremity Fellow
Cleveland Clinic
Cleveland, Ohio
Xavier C. Simcock, MD
Hand and Upper Extremity Fellow
Cleveland Clinic Foundation
Cleveland, Ohio
Beth Paterson Smith, PhD

Professor
Wake Forest School of Medicine
Winston-Salem, North Carolina
Dean G. Sotereanos, MD, PhD

Clinical Professor of Orthopaedic Surgery
University of Pittsburgh School of Medicine
Orthopaedic Specialists
James W. Strickland, MD
Emeritus Professor of Orthopaedic Surgery
Indiana University Medical Center
Medical Director and Hand Surgeon
Department of Orthopaedic Surgery/Hand Surgery
Saint Francis Hospital
Indianapolis, Indiana
Catherine Szado, OT/L, CHT

Occupational Therapist
Department of Physical Medicine
Cleveland, Ohio
Joelle Tighe, BS
Research Assistant
Community Medicine, Inc.
Eugene Y. Tsai, MD
Resident
University Hospitals Case Medical Center
Cleveland, Ohio
Joseph Upton, MD
Professor of Surgery
Shriners Hospital for Children—Boston
Beth Israel Deaconess Hospital
Carley B. Vuillermin, MBBS, FRACS

Instructor in Orthopaedics
Staff Orthopaedic Surgeon
Peter M. Waters, MD
John E. Hall Professor of Orthopaedic Surgery
Orthopedic Surgeon-in-Chief
Michael D. Wigton, MD
Resident Physician
Allegheny General Hospital
Allegheny Health Network
E. F. Shaw Wilgis, MD
Chief Emeritus
Baltimore, Maryland
Bradon J. Wilhelmi, MD, FACS

Chief and Professor
Program Director
Plastic Surgery Residency
Hiram Polk Department of Surgery
University of Louisville
University Hospital
Jewish Hospital and Norton Hospital
Louisville, Kentucky
Raymond A. Wittstadt, MD
Baltimore, Maryland
Andrew Yee, BS
Research Associate
Plastic and Reconstructive Surgery
Washington University School of Medicine
St. Louis, Missouri
Ashraf M. Youssef, MD
Resident
Case Western Reserve University School of Medicine
University Hospitals of Cleveland
Cleveland, Ohio
Jonathan Amer Zelken, MD

Housestaff, Department of Hand Surgery
Union Memorial Hospital
Baltimore, Maryland
Neal B. Zimmerman, MD
Attending Surgeon
Baltimore, Maryland
Ryan M. Zimmerman, MD
Hand Surgery Fellow
Baltimore, Maryland
2016
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Library of Congress Cataloging-in-Publication Data
The hand / [edited by] Steven D. Maschke, Thomas J. Graham, Peter J. Evans. — Third edition.
p. ; cm. — (Master techniques in orthopaedic surgery)
Preceded by The hand / editors, James W. Strickland, Thomas Graham. 2nd ed. c2005.
Includes bibliographical references and index.
ISBN 978-1-4511-8278-1 (alk. paper)
I. Maschke, Steven D., editor. II. Graham, Thomas J., editor. III. Evans, Peter J. (Peter John), 1961-, editor. IV.
Series: Master techniques in orthopaedic surgery.
[DNLM: 1. Hand—surgery. 2. Hand Deformities—surgery. 3. Hand Injuries—surgery. WE 830]
RD559
617.5′75059—dc23
2015030387
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Dedication
To Tracie, Mason, Michael, and Lillian, without whom none of my success would be possible.
SDM
To my family, colleagues, students, and patients.

TJG
To Caroline, my children, colleagues, trainees, and patients.

PJE
Series Preface
Since its inception in 1994, the Master Techniques in Orthopaedic Surgery series has become the gold standard
for both physicians in training and experienced surgeons. Its exceptional success may be traced to the
leadership of the original series editor, Roby Thompson, whose clarity of thought and focused vision sought “to
provide direct, detailed access to techniques preferred by orthopedic surgeons who are recognized by their
colleagues as ‘masters’ in their specialty,” as he stated in his series preface. It is personally very rewarding to
hear testimonials from both residents and practicing orthopedic surgeons on the value of these volumes to their
training and practice.
A key element of the success of the series is its format. The effectiveness of the format is reflected by the fact
that it is now being replicated by others. An essential feature is the standardized presentation of information
replete with tips and pearls shared by experts with years of experience. Abundant color photographs and
drawings guide the reader through the procedures step by step.
The second key to the success of the Master Techniques series rests in the reputation and experience of our
volume editors. The editors are truly dedicated “masters” with a commitment to share their rich experience
through these texts. We feel a great debt of gratitude to them and a real responsibility to maintain and enhance
the reputation of the Master Techniques series that has developed over the years. We are proud of the progress
made in formulating the third-edition volumes and are particularly pleased with the expanded content of this
series. Six new volumes will soon be available covering topics that are exciting and relevant to a broad cross-
section of our profession. While we are in the process of carefully expanding Master Techniques topics and
editors, we are committed to the now-classic format.
The first of the new volumes is Relevant Surgical Exposures—which I have had the honor of editing. The
second new volume is Pediatrics. Subsequent new topics to be introduced are Soft Tissue Reconstruction,
Management of Peripheral Nerve Dysfunction, Advanced Reconstructive Techniques in the Joint, and finally
Essential Procedures in Sports Medicine. The full library thus will consist of 16 useful and relevant titles.
I am pleased to have accepted the position of series editor, feeling so strongly about the value of this series to
educate the orthopedic surgeon in the full array of expert surgical procedures. The true worth of this endeavor
will continue to be measured by the ever-increasing success and critical acceptance of the series. I remain
indebted to Dr. Thompson for his inaugural vision and leadership, as well as to the Master Techniques volume
editors and numerous contributors who have been true to the series style and vision. As I indicated in the preface
to the second edition of The Hip volume, the words of William Mayo are especially relevant to characterize the
ultimate goal of this endeavor: “The best interest of the patient is the only interest to be considered.” We are
confident that the information in the expanded Master Techniques offers the surgeon an opportunity to realize
the patient-centric view of our surgical practice.
Bernard F. Morrey, MD
Preface
Seemingly since Jim Strickland and I edited the last volume of Master Techniques in Orthopaedic Surgery: The
Hand, in 2005, everything in health care has changed. We all recognize that our industry is at an historic
inflection point and there is no stakeholder that is immune from feeling pressure and experiencing ambiguity. The
largest concentrated sector of our economy is seeing its biggest rate of change ever.
What has not changed is that the “center of the medical universe” remains where the doctor and the patient
meet. If you are a Hand Surgeon, that comes with a responsibility to be intellectually and technically prepared
while exhibiting empathy and concentrating on the patient experience. I do not believe there has been a better
vehicle for passing along the nuanced information that may make the difference between success and
suboptimal results than this entire Master Techniques series.
As I saw these contributions coming in from some of the most accomplished surgeons and educators in our field,
I was vividly reminded that our specialty is dynamic. Our colleagues remain innovative problem solvers, keen
clinical anatomists, and master technicians. They also take the role as teacher very seriously.
I know that all of our readers are lifelong students of Hand Surgery. That is why we remain stimulated after
decades of practice—by the subject matter and especially by the opportunity to help the next patient. That is why
I am so proud of my two Co-Editors, Drs Peter Evans and Steve Maschke. They are the next generation of
leaders who bring all the assets together that make our specialty vital and collegial. Just as Jim passed the baton
of responsibility for this book to me, I am humbled to pass it to them.
At different times in our career, we are students and teachers…mentors and mentees…some of us have been
both doctors and patients. Since the last volume, I almost lost my life to a rare medical illness but came back
after over a year away from Hand Surgery to resume practice. I know how important our work is and how
precious the gift to do it for a living remains.
Whether you are looking at this electronically on a computer or mobile device, or the “old fashion way” with a
book in your hand, I trust that the dedication and expertise of the contributors seep through. The medium may
have changed, but being the most informed and technically advanced surgeon you can be never goes out of
style. You have made the choice to improve your knowledge on behalf of your patients by reading this book.
That makes you a Master. Good luck and best wishes.
Chief Innovation Officer and Vice Chairman of Orthopaedic Surgery
Cleveland Clinic
Cleveland, Ohio
Preface to the Second Edition
The intellectual and technical challenges of sophisticated hand surgery are practically unparalleled in the
endeavors of the clinical sciences. Intimate knowledge of fine anatomy; well-planned and skillfully executed
surgical exercises; and attention to detail before the operation, intraoperatively, and during rehabilitation are all
required to maximize outcome.
Respect for time-tested techniques, with an open-minded approach to evolving surgical options, is demanded if a
contemporary surgeon is to deliver the ultimate level of care to the wide array of patients seeking help for hand
problems due to traumatic, congenital, inflammatory, neoplastic, or degenerative conditions.
The Master Techniques series has already risen to a unique niche in the dissemination of highlevel surgical
education. The initial edition of The Hand laid the groundwork for capturing the thinking and unique perspective
that our distinguished colleagues have developed over years of practice. Students of Hand Surgery will see that
this volume has further expanded the spectrum of procedures and pearls.
We credit the laureates who have contributed to this edition with concise words and vivid images. They have
captured the salient points by recognizing the germinal components of the problems and the solutions. With
tremendous photography and illustration strengthening the descriptions, the compendium of the written word and
visual learning tools has resulted in an important contribution to our specialty.
Just as we shared the strong bond between mentor and pupil, we wanted to capture that singular experience for
teaching and learning. To pass along our true thinking about our work, and ask our valued friends to do the
same, is an honor. In this way, all the authors can feel the flexibility and intimacy that come with disseminating
knowledge from one colleague to the next in one of the best media we can imagine. All of the contributors
appreciated the responsibility of accepting and completing these assignments and fulfilled them expertly.
All of those who worked on Master Techniques in Orthopaedic Surgery: The Hand hope that this volume
connects with our readers in a way that makes it is a resource and stimulus for their own development. It is a text
that is dynamic, not simply a moment frozen in our timeline of hand surgery, but a catalyst for greater discourse
and creativity concerning the clinical tests that we all face.
Ultimately, there will be acceptance, inquiry, controversy, and change in almost all of the views expressed
herein. That is the nature of our specialty and of all of medicine. For now, this is the best effort of many of the
most dedicated and prolific contributors to our specialty, who also share a passion for teaching and lifelong
learning. We hope the book makes a positive impact on the practice of our readers and in the lives of their
patients.
James W. Strickland, MD
Preface to the First Edition
This book is a collection of descriptions of operations as performed by acknowledged “masters.” There is no
attempt to be comprehensive or all inclusive. Instead, common operative procedures have been selected and the
preferred operative approach of the author is illustrated and described.
A major strength of the volume is the quality of the illustrations. Uniformity of this quality is assured by having the
same artist illustrate the entire book. In addition, a single uniform format has been adopted so the reader can
easily become familiar with the style as successive chapters are read.
The best way to use this book is to read a chapter that pertains to a particular patient and operation that you are
planning. Add your own experiences and preferences, but remember that the procedures described have served
the authors in numerous circumstances. I guarantee that you will find each chapter useful and informative.
Curtis B. Sledge, MD
Video Content
Video 10-1 Acute trauma 1.
Video 10-7 Posttraumatic reconstruction 1.
Video 10-8 Posttraumatic reconstruction 2.
Video 10-9 Burn and congenital hand reconstruction 1.
Video 10-10A Burn and congenital hand reconstruction 2.
Video 10-10B Burn and congenital hand reconstruction 3.
Video 10-10C Burn and congenital hand reconstruction 4.
Video 10-10D Burn and congenital hand reconstruction 5.
Video 10-10E Burn and congenital hand reconstruction 6.
Video 10-11A Surgical technique 1.
Video 10-11B Surgical technique 2.
Video 10-11C Surgical technique 3.
Video 10-11D Surgical technique 4.
Video 10-11E Surgical technique 5.
Video 10-11F Surgical technique 6.
Video 10-11G Surgical technique 7.

Video 10-11H Surgical technique 8.
Video 10-11I Surgical technique 9.
Video 10-11J Surgical technique 10.
Video 10-11K Surgical technique 11.
Video 10-11L Surgical technique 12.
Video 10-11M Surgical technique 13.
Video 10-11N Surgical technique 14.
Video 10-11O Surgical technique 15.
Video 10-11P Surgical technique 16.
Video 10-12 Surgical technique 17.
Video 10-13A Surgical technique 18.
Video 10-13B Surgical technique 19.
Video 10-14 Surgical technique 20.
Video 10-15A Postopertative management 1.
Video 10-15B Postopertative management 2.
Video 10-16 Results.
Video 11-1 Elson's test for integrity if central slip.
Video 17-1 Pre-op.
Video 17-2 Donor.
Video 17-3 Setting extensor synch tension.
Video 17-4 Confirming tension.
Video 17-5 Post-op.
Video 22-1 Nerve transfer: median to radial nerve transfer presentation.

Video 22-2 Median to radial nerve transfer.
Video 23-1 Post-op.
Video 29-1 Homodigital island flap.
Video 31-1 Arterial and peripheral sympathectomy for vasospastic disease.
Video 33-1 Opposition transfer and UCL reconstruction for type II thumb hypoplasia.
Chapter 1
Surgical Approaches to the Digits and Treatment of Finger
Infections
Jason M. Rovak
Surgical exposure is both basic and critical to any surgical procedure's success. While many surgical disciplines
have standard approaches regardless of the underlying pathology, in the upper extremity, the surgical approach
can require careful preoperative planning that is tailored to the individual procedure. The approach must
maximize visualization while protecting underlying structures both during the procedure and in the course of
postoperative healing. A carefully planned approach will also allow for the unexpected intraoperative finding that
requires a change of course. In this chapter, we will address common surgical approaches in the digits as well as
treatment for common finger infections.
VOLAR APPROACHES TO THE DIGIT

The primary principle governing exposure of the volar structures is avoiding linear scars across flexion creases.
Since scars contract linearly, scars that cross flexion creases perpendicular to the crease can lead to
postoperative flexion contractures. In trauma situations, the exposure is dictated by the
P.2
wound, and linear scars may need to be addressed either by proactively redirecting the orientation of the wound
during closure with Z-plasties or by addressing the contractures at a second procedure in the subacute/chronic
period if a contracture develops. In elective settings, the key is to avoid the problem altogether with careful
preoperative planning.
FIGURE 1-1 Index finger: Standard Bruner incisions; long finger: Mini-Bruner incision; ring finger: Bruner incision
with curved flap tips; small finger: Incision within the joint flexion crease.
There are three predominant methods of avoiding linear scars along the volar axis of the digit. These methods
can either be used in isolation or combined:
1. Cross the joint crease obliquely.

2. Place the incision in the flexion crease.
3. Place the incision along the lateral aspect of the digit.
The first method entails a series of zigzag incisions that cross the flexion creases at roughly 45-degree angles.
The incision extends from the radial to the ulnar aspect of the digit. This approach was originally described by
Bruner (1) and provides excellent exposure of all volar structures. These incisions can be extended proximally
and distally as far as the situation requires, including the palm and wrist (Fig. 1-1, index finger). Not every
situation requires exposure of the whole volar surface, such as a single digital nerve laceration without tendon
involvement. In these settings, a “mini-Bruner incision” may be adequate, placing the apex of the incision in the
central volar aspect of the digit without extending completely across the digit (Fig. 1-1, long finger). Some
surgeons prefer to round off the tips of the flaps to avoid tip necrosis (Fig. 1-1, ring finger). I have not found tip
necrosis to be a problem with pointed flap tips.
The next method involves placing the incision directly in the flexion crease (Fig. 1-1, small finger). While the
incision obviously involves the flexion crease, the direction of scar contracture is parallel to the crease, and
perpendicular to the axis of the digit, so it does not lead to flexion contractures. The scar is nicely hidden within
the flexion crease for excellent postoperative cosmesis. This method is generally not used in isolation, as it
provides only a small window of exposure. I have only used this method in isolation as a counterincision when
irrigating the flexor sheath, which will be described later in this chapter, or as an exposure for a trigger finger
release, which is well described elsewhere.
Finally, incisions can be placed on the lateral aspect of the digit. When correctly designed, these incisions are
placed in the “midaxial” line. This line connects the center of the phalangeal condyles when viewed from the
side. While linear and crossing joints, an incision in the midaxial line does not contribute to a joint contracture
since the scar is directly in line with the joints' axis of rotation. A contracting scar volar to the axis of rotation, on
the other hand, provides a flexion force. In order to identify the midaxial line, the digit is placed in flexion and the
apex of the joint crease is marked. This indicates the center of the condyle (Fig. 1-2). These points are
connected
P.3
to form the midaxial line. In isolation, midaxial incisions allow access to the PIPJ for contracture release. More
commonly, these incisions are combined with Bruner incisions to provide wide exposure of the volar digital
structures as is required when treating extensive infections, treating pressure injection injuries, or performing
flexor tenosynovectomy, or in zone II flexor tendon repairs (Fig. 1-3). Some surgeons feel that another advantage
to this approach is that it avoids scar tissue across the volar structures, though again, I have not found this to be
a problem with a standard Bruner approach.
FIGURE 1-2 Marking the midaxial line. With a flexed digit, the apex of the joint flexion crease indicates the
appropriate incision placement.
FIGURE 1-3 Midaxial incisions combined with Bruner extensions.
P.4
DORSAL APPROACHES TO THE DIGIT
Dorsal approaches to the digits are both more forgiving and more variable. Beginning distally, the nail bed is
generally exposed in crush injuries to address nail bed lacerations and open fractures of the distal phalanx.
Subungual masses or lesions such as glomus tumors or biopsy for subungual melanomas are addressed
similarly. The fingernail can be either partially or totally removed depending on the extent of the required
exposure. This is achieved by placing the sharper end of a Freer elevator under the distal aspect of the nail and
carefully elevating the nail from the nail bed, taking care to ensure that damaged portions of the nail bed remains
with the undamaged portion of the nail bed and do not come off with the nail. The nail is freed from the lateral
aspects of the nail fold as well. The elevator is then placed under the eponychial fold on top of the nail, and the
nail is removed in an atraumatic fashion. I clear any adherent soft tissue with a Freer elevator, soak the nail in
Betadine, rinse with saline, and place the nail on gauze for use at the end of the case. The germinal matrix,
under the eponychial fold, is inspected to determine the proximal extend of the injury. Occasionally incisions on
the lateral aspect of the nail fold are necessary to provide adequate proximal exposure (Fig. 1-4, ring finger). A
small double hook is used to retract the dorsal roof of the nail fold so the fold can be inspected for masses and
the proximal aspect of the nail bed inspected for trauma. Nail bed lacerations and any required incisions in the
nail fold can be closed using either 5-0 or 6-0 fast-absorbing gut suture. In order to prevent scar tissue
(synechia) from disturbing nail growth, the nail fold is stented open with the previously removed fingernail. I place
a horizontal mattress stitch through the dorsal nail fold and through the proximal aspect of the nail to secure the
nail under the fold and place one distal stitch through the nail plate and distal tip to prevent the end from catching
and avulsing. If the fingernail itself is unavailable, trim foil from the suture pack to an appropriate size and stent
the nail fold.
Exposing the dorsal aspect of the distal interphalangeal joint (DIPJ) is required to excise mucous cysts or
perform DIPJ arthrodesis. Either an “H-” or “Y”-shaped incision provides exposure of the radial and ulnar aspect
of the joint (Fig. 1-5, small and ring fingers) and allows proximal and distal exploration if needed. If a mass is
situated away from the midline, full exposure of the joint may not be necessary. In this case, the incision can be
limited to one-half of the “H” or “Y” (Fig. 1-5, index and long fingers).
The dorsal aspect of the proximal interphalangeal joint (PIPJ) can be addressed with either a straight line
incision centered over the joint or a curvilinear incision (Fig. 1-6). Skin flaps are easily elevated just over the
paratenon of the extensor tendon. In the index, long, ring, and small fingers, the sensory nerve branches
innervating the dorsal aspect of the digit arise from the digital nerves on the volar aspect of the digit. These
branches are raised within the skin flaps, and I do not make an effort to identify branches during these
approaches. The dorsal thumb, on the other hand, is innervated by branches of the radial sensory nerve. These
branches are identifiable and if damaged can lead to noticeable numbness or discomfort. For PIPJ arthrodesis, I
use a straight line incision, as scar contracture is not an issue. To address stiffness that requires either tenolysis
or capsulectomy, I will use a large curvilinear incision. This provides wide exposure of all dorsal structures and
also allows access to the lateral and volar structures if necessary.
FIGURE 1-4 Ring finger: Incisions to reflect the dorsal nail fold. Long finger: Marsupialization incisions.
P.5
FIGURE 1-5 Dorsal approaches to the distal interphalangeal joint.
FIGURE 1-6 Dorsal approaches to the proximal interphalangeal joint.
INFECTIONS
Felon
Infections of the volar pad of the fingertip present with pain and swelling, usually preceded by a puncture injury.
The fingertip is tense and painful with palpation. Many times, there is an area on the volar pad that is “pointing”
and indicates the site of maximum purulence. The symptoms are isolated to the tip of the digit and do not extend
proximally into the finger. Motion is generally not painful. The differential for any volar finger infection must
include flexor tenosynovitis, septic joint,
P.6
and gout, though these are usually easily differentiated with a targeted physical exam. Treatment is primarily
surgical. Incision and drainage can be performed under local anesthesia. Lateral incisions can be used to avoid
scars and subsequent discomfort over pinch surfaces; however, I generally favor an incision directly over the
point of maximum fluctuance and pain. The volar soft tissue has septa extending from the distal phalanx to the
skin, and a tenotomy scissors is used to bluntly dissect through the septa to ensure that there are no loculated
collections. The wound is irrigated then packed with ¼-inch plain packing, and a sterile dressing is applied. I
have the patient begin range of motion the following day with daily soaks and packing changes until the wound
heals. Cephalexin is generally adequate empiric coverage, though oral antibiotic therapy is tailored to
intraoperative cultures as results become available.
Paronychia
The eponychial fold is a common site for finger infections, especially in patients who pick at hangnails or bite
their nails. These present with a focal area of erythema and tenderness over the lateral or proximal eponychial
fold. Oral antibiotic treatment alone is frequently successful, and hot water soaks may encourage spontaneous
drainage; however, if a conservative course does not resolve symptoms or if the area is fluctuant and does not
spontaneously drain, surgical incision and drainage may be necessary. Following digital block, a no. 15 or no. 11
blade is placed through the distal aspect of the eponychial fold with the blade oriented parallel to the nail. The
wound is washed out and packed, with local wound care beginning the following day. A 10- to 14-day course of
antibiotics should be completed to prevent recurrence.
Untreated paronychia can spread to the subungual space or to the volar soft tissues of the digit. In cases with
subungual purulence, the portion of the nail overlying the infected bed is removed to adequately drain the
infection and release the pressure on the nail bed in an attempt to preserve normal nail growth. If purulence has
spread into the volar soft tissues, release of the volar soft tissues can generally be performed through the dorsal
incision, though in severe cases, a counterincision in the volar pad can facilitate thorough washout.
Chronic or recurring paronychia may develop, especially in those with prolonged occupational water exposure.
These tend to be fungal in origin, whereas acute paronychia is typically bacterial. Chronic paronychia can be
recalcitrant to standard incision and drainage and may require marsupialization of the eponychial fold. This
involves excising an ellipse of dorsal soft tissue just proximal to the eponychial fold, followed by healing by
secondary intention (Fig. 1-4, long finger). Oral antifungal therapy may be necessary as well, depending on the
offending organism.
Septic Joints
Diagnosis of septic DIP and PIP joins is primarily clinical, as arthrocentesis can be technically difficult, and there
is generally inadequate fluid available for diagnostics. Pain with axial load and passive motion at the joint is the
hallmark of a septic joint. Crystalline arthropathy should always be within the differential, especially in a patient
with a previous history. Expedient surgical drainage is key to prevent chondral damage or subsequent
osteomyelitis. The joints are approached dorsally as described above. An arthrotomy is created lateral to the
midline to avoid damage to the extensor mechanism. At the DIPJ, the capsulotomy is created lateral to the
terminal extensor slip. The PIP joint is opened between the central slip and lateral band. The joint is irrigated
with a small Angiocath, and I typically place a small Penrose drain in the joint to facilitate continued drainage.
Wound care and range of motion begin the following day. I generally remove the drain 48 hours after the initial
surgical procedure. I will consult infectious disease for intravenous antibiotics at the time of initial evaluation,
though expeditious surgical treatment is key to preventing long-term sequelae. As with any infectious or traumatic
insult to the small joints in the fingers, postoperative stiffness is common. Early therapy is key to maximizing the
patient's eventual outcome.
Flexor Tenosynovitis
Purulent flexor tenosynovitis develops when bacteria are traumatically introduced into the flexor sheath. The
infection quickly spreads proximally and distally along the flexor sheath and can cause scarring within the sheath
or tendon rupture if not treated urgently. Patient presentation was classically described by Kanaval (2), and the
hallmark findings bear his name. Kanaval's signs include (a) fusiform swelling of the digit, (b) finger held in a
flexed posture, (c) pain with passive digit extension, and (d) marked tenderness to palpation along the entire
sheath, including the palm over the A1 pulley. I have found the last two to be the most reliable when making the
diagnosis, as finger swelling can come from superficial infections, edema, gout, etc., and any finger swelling can
lead to a flexion posture. If the patient has pain along the volar length of the digit, including the distal palm, and
pain with passive extension, purulent flexor tenosynovitis should be high on the differential.
P.7
Incision and drainage can be performed with local anesthesia; however, if I am concerned about additional
purulence in the volar soft tissue that may require more extensive dissection, or if appropriate lighting and
instrumentation are not available for a safe local anesthesia case, I will perform this procedure in the operating
room with general anesthesia. Additionally, extensively infected areas can be difficult to anesthetize. Infected soft
tissue has a more acidic local environment. Local anesthetics themselves are weak bases and will not cross cell
membranes in their protonated, charged, form. Adding sodium bicarbonate to the anesthesia can increase the
chances of successful anesthesia as well as decrease the pain of injection. If the infection is fairly early, local
anesthesia has a high chance of success, and I expect a limited tourniquet time I am comfortable using a local
anesthesia for these cases either in the emergency department or operating room. If any of the above are in
question, it is better to use a general anesthetic, avoiding patient discomfort and movement, which can
compromise exposure and efficacy of the washout.
An incision is made directly over the flexor sheath in the palm, and blunt dissection is taken down to the flexor
sheath just proximal to the A1 pulley. The flexor sheath is usually bulging, and purulence will be obtained as
soon as the sheath is entered. I obtain cultures at this time. A volar counterincision is made in the DIP joint
flexion crease. The flexor sheath is opened transversely at the A5 pulley level. I will then place a small Angiocath
or pediatric feeding tube into the flexor sheath in the proximal wound and flush distally with normal saline. The
fluid should flow freely and egress from the distal wound. Occasionally, the digit needs to be slightly flexed or
extended to allow easy fluid flow. After copious irrigation, both wounds are packed with either plain packing or a
Penrose drain. Again, infectious disease consultation and hand therapy are involved early. I have the patient
begin whirlpool the following day, and generally remove the drains 48 hours after the initial washout.
The predominant causative organism in hand infections of all types is Staphylococcus aureus. Cephalexin
generally provides adequate empiric coverage until culture results are available and also covers streptococcus.
Bactrim (trimethoprim/sulfamethoxazole) is also an excellent first-line treatment. While Bactrim does not cover
streptococcus, most methicillin-resistant Staphylococcus aureus (MRSA) is sensitive to Bactrim. Bactrim has
excellent soft-tissue penetration and oral bioavailability, is inexpensive, and has twice per day dosing, facilitating
patient compliance. Cultures should be obtained in the OR with any infection. In cases that clearly require
operative management with a readily available OR, I will hold off on antibiotic administration and will counsel the
ER to hold off on antibiotic administration, until after the procedure to obtain accurate operative cultures.
CONCLUSIONS
Surgical exposures in the digits are varied and must be tailored to the procedure. Preoperative planning
should take unexpected pathology as well as possible future operations into account. Adequate exposure
not only facilitates successful completion of the procedure at hand but also can prevent future complications
directly related to scar tissue formation from the procedure.
REFERENCES
1. Bruner JM: The zig-zag volar digital incision for flexor tendon surgery. Plast Reconstr Surg 40(6): 571-574,
1967.
2. Kanavel A: Infections of the hand. 4th ed. Philadelphia, PA: Lea & Febiger, 1921.
Chapter 2
Palmar Approaches
Michael Darowish
CARPAL TUNNEL APPROACH

Indications
The carpal tunnel may need to be approached for median nerve decompression for isolated carpal tunnel
syndrome, for acute carpal tunnel syndrome, or in conjunction with fasciotomy for compartment syndrome.
The carpal tunnel may also need to be explored in cases of infection or penetrating trauma, or may need to
be opened to identify retracted proximal stumps of finger flexor tendons during repair or reconstruction. The
carpal tunnel approach can be extended proximally into the volar approach of Henry to address fractures of
the distal radius, as well as permitting access to the volar wrist ligaments, such as in the case of perilunate
dislocations. Similarly, tenosynovectomy of the flexor tendons for rheumatoid disease or mycobacterial
infection can be performed through this extended approach (Fig. 2-1).
Technique
A variety of approaches for decompression of the median nerve have been described, including one- and two-
portal endoscopic, proximal or distal minimally invasive releases, or more traditional open approaches.
Regardless of the approach chosen, certain anatomic considerations remain constant.
The carpal tunnel runs from Kaplan's cardinal line distally to the wrist flexion crease proximally. Just distal to the
transverse carpal ligament (TCL) and the carpal tunnel lays the superficial palmar arch, typically 18 mm distal to
the distal edge of the ligament (1). The TCL attaches to the scaphoid and trapezium radially and the pisiform and
hamate ulnarly.
The recurrent motor branch of the median nerve must be protected. Its anatomy is variable. Most commonly, the
nerve arises distal to the carpal tunnel, traveling proximally to the thenar muscles. However, approximately 30%
of the time, the nerve branches within the carpal tunnel, and then travels in the tunnel until just distal to the TCL,
where the recurrent branch turns superficially and radially back into the thenar muscles. Alternatively,
approximately 20% of the time, the recurrent branch comes off the median nerve within the carpal tunnel and
pierces through the TCL into the thenar musculature (transligamentous). More rare variations include the
recurrent branch arising from the ulnar side of the median nerve, multiple motor branches, or division of the
median nerve proximal to the carpal tunnel, with the motor nerve then following any of the paths described above
to reach the thenar musculature (Fig. 2-2).
Because of this high degree of variance, care must be taken when dividing the TCL to mitigate the potential for
iatrogenic injury to the motor branch. By approaching the TCL at its ulnar border, greater distance from the
recurrent branch is maintained, protecting the nerve. Should the physician encounter a substantially large
palmaris brevis or hypertrophic muscle atop the TCL (2,3) or an aberrant accessory flexor pollicis brevis muscle
(4), greater care should be taken, as these are associated with a higher incidence of nontraditional course of the
motor branch.
P.10
FIGURE 2-1 Clinical example of extensile carpal tunnel approach for tenosynovectomy. A: Dots demonstrate the
course of the incision. B: After subcutaneous dissection, the median nerve is identified and isolated (Penrose
drain is around the nerve). C: After excision of tenosynovitis.
The palmar cutaneous branch of the median nerve branches from the median nerve approximately 5 to 6 cm
proximal to the wrist flexion crease. It then travels with the median nerve for an additional 2 to 3 cm before
running along the ulnar aspect of the flexor carpi radialis (FCR) tendon. At the flexor retinaculum, it travels
between the two layers of the retinaculum, ultimately dividing into three branches, providing sensation to the
palm overlying the thenar musculature. By staying ulnar and taking care to divide the antebrachial fascia under
direct vision, injury to this branch can be avoided.
In an open approach to the carpal tunnel, a longitudinal incision along the radial border of the ring finger, starting
at Kaplan's cardinal line (a line extended from the ulnar border of the radially abducted thumb), and extending
toward the wrist flexion crease just ulnar to the palmaris longus tendon is made. If no proximal extension of the
approach is required, the incision should end distal to the wrist flexion crease, as there is some suggestion of
increased pain with more proximal incisions. Should the need to cross the wrist flexion crease exist (such as in
cases of tenosynovectomy or extensile approaches for trauma), the incision should cross the flexion crease at an
oblique angle, taking care to veer ulnarly to avoid injury to the palmar cutaneous branch of the median nerve
(Fig. 2-3).
Immediately below the skin, there exists a layer of subcutaneous fat. This can be elevated as a pedicled flap
based on branches the ulnar artery (hypothenar fat flap) to alter the perineural environment in cases of revision
carpal tunnel release (CTR) where significant scarring of the median nerve to the TCL is present. Otherwise, this
layer can be divided without consequence.
Dissection is carried down to the palmar fascia, which is identified and divided in line with its fibers. The TCL is
then visualized. If thenar musculature is encountered on the ligament, the ulnar aspect of its fascia is incised,
and the muscle fibers are bluntly swept from ulnar to radial to expose the ligament. Should pockets of fat be
encountered, this should alert the surgeon to carefully dissect these areas, as this is often the sign of nearby
neurovascular structures, including the recurrent motor branch. Once the ligament is exposed, it is divided along
its ulnar aspect. At the distal end, bright yellow fat is encountered, denoting that dissection has been carried far
enough distally, and once again alerting the surgeon to the nearby location of the palmar arch (Fig. 2-4).
P.11
FIGURE 2-2 Variations in the course of the recurrent motor branch of the median nerve. A: Extraligamentous. B:
Subligamentous division of the median nerve with recurrent entrance to the thenar musculature. C:
Transligamentous course of the recurrent motor branch. D: Branching from the ulnar aspect of the median nerve.
E: Lying atop the TCL. (From Mackinnon SE, Novak CB. Compression neuropathies. In: Wolfe SW, Pederson
WC, Hotchkiss RN, et al., eds. Green's operative hand surgery. 6th ed. Philadelphia, PA: Elsevier, 2011.)
FIGURE 2-3 Incision for proximal extension of the carpal tunnel approach. Note the incision deviates ulnarly to
avoid injury to the palmar cutaneous branch of the median nerve (black arrow). (From Catalano LW, Zlotolow
DA, Lafer MP, et al.: Surgical exposures of the hand and wrist. J Am Acad Orthop Surg 2: 48-57, 2012.)
P.12
FIGURE 2-4 Clinical photograph (A) and artist's rendering (B) demonstrating carpal tunnel release. Bright yellow
fat encountered at the distal aspect of the TCL is a reliable indicator that dissection has extended distally enough
to fully decompress the median nerve at the carpal tunnel and that dissection further distally should proceed with
care, as the palmar arch is near. (From Madhav TJ, To P, Stern PJ: The palmar fat pad is a reliable
intraoperative landmark during CTR. J Hand Surg Am 34: 1204-1209, 2009.)
To expose the proximal ligament and antebrachial fascia, dissecting scissors are used to bluntly open a pocket
above the ligament, and a Ragnall or House retractor is placed into the pocket to elevate the skin and palmar
fascia away from the TCL and antebrachial fascia. By allowing the wrist to extend, the structures to be divided
fall dorsally from the more superficial structures, and can then be released under direct vision with a no. 15
blade. During this portion of the case, the surgeon should either move to the end of or move to the other side of
the hand table to allow unrestricted visualization and a more controlled release using one's dominant hand.
Tips and Pearls

In my practice, for isolated CTR, I typically utilize Bier block (intravenous regional anesthesia) with or without
sedation, according to patient preference. Rarely do I have patients who are not willing or able to tolerate this,
and general anesthesia is used. I prefer this to local anesthesia, which can blur tissue planes and obscure small
nerve branches, which can provide difficulties for the surgeon and when working with trainees. I use a single-
forearm tourniquet with 20 to 25 mL of 0.5% lidocaine; forearm tourniquets are well tolerated for these short
procedures, and the dose of lidocaine is minimized, allowing the tourniquet to be safely deflated sooner than
when larger volumes are used. Because of the short tourniquet duration, a double tourniquet is not necessary.
Tourniquet pressure is set at least 100 mm Hg higher than systolic pressure; at least 250 mm Hg, but possibly
higher depending on the patient's blood pressure in the operating room. It is critical to set tourniquet pressure
high enough to avoid a venous tourniquet, which significantly complicates the surgery and makes visualization
difficult, as the tourniquet cannot be deflated for at least 20 minutes after lidocaine injection in order to prevent
systemic side effects of the lidocaine. By initiating the block prior to prepping and draping, the anesthetic has
typically had enough time to take effect prior to initiating the surgical portion of the case; by the time that the
dressings are applied, the tourniquet has been inflated for 20 minutes and can be safely deflated without fear of
systemic side effects from the lidocaine.
In cases of distal radius fracture requiring CTR, I prefer using two separate approaches—one for the distal
radius fixation and a separate CTR rather than one extended incision. Decompression of the carpal tunnel has
also been described by releasing the radial insertion of the TCL at the distal aspect of the approach for open
reduction and internal fixation (ORIF) of a distal radius fracture (5,6).
Complications
As detailed above, great care must be taken to avoid injury to the palmar cutaneous and recurrent motor
branches of the median nerve. Additionally, complete decompression of the median nerve must be
confirmed by either direct visualization or palpation; the most common reason for failure of median nerve
release is incomplete division of the TCL.
P.13
While not a complication, patients with preexisting hand or basal joint arthritis can become more
symptomatic following CTR, as their arthritic pain is better perceived following median nerve
decompression. Alteration in the mechanical stresses of the trapeziometacarpal or pisotriquetral joints due
to division of the attached ligaments also contributes to this increased symptomatology. Preoperative
counseling for this is critical to avoid patient dissatisfaction.
Pillar pain is a persistent ache at the scar, thenar, and hypothenar eminences following division of the TCL.
There is no clear-cut definition of this syndrome, and as such, its incidence is varied in the literature from
19% to 61% (7). The cause of pillar pain is similarly unclear, with various authors pointing to small
cutaneous nerves, unmyelinated c-fibers within the TCL, or nerve ending entrapment within postoperative
scar. Others feel this is a musculoligamentous phenomenon due to alterations in the carpal arch geometry
following release. Treatments have been described with scar massage, stress loading therapy,
extracorporeal shock wave therapy (ESWT), or infiltration of local anesthetic.
Recently, greater attention has been given to presentation of trigger finger after CTR. The incidence of
trigger fingers in the postoperative period following CTR has been reported from 3% to 11%. Diabetic
patients are at higher risk of developing trigger digits following CTR (8). Several recent studies have raised
the possibility that division of the antebrachial fascia in conjunction with the TCL increases the incidence of
trigger fingers, possibly by allowing greater volar translation of the flexor tendons, allowing bowstringing
and, as such, altering the angle of entrance at the A1 pulley, increasing forces and friction over these
tendons (9,10).
In cases where tenosynovectomy or significant mobilization and manipulation of the flexor tendons is
performed (such as to access the ligaments of the floor of the carpal tunnel), the potential for peritendinous
fibrosis and finger stiffness is significant, and immediate range of motion should be initiated, with
consideration for supervision by a hand therapist.
GUYON'S CANAL APPROACH

Indications
The ulnar nerve may need to be explored or decompressed distally to relieve pressure within Guyon's canal
or to explore the nerve following trauma. Knowledge of the anatomy of this area is essential when excising
the hook of the hamate for fracture or nonunion. This approach may also be required to identify the ulnar
motor nerve fascicle for anterior interosseous nerve (AIN)-to-ulnar motor nerve transfers for severe ulnar
neuropathy or very proximal ulnar nerve injury.
Preoperative Preparation
Careful inspection for masses or enlargement of the volar ulnar wrist can suggest the presence of a space
occupying lesion compressing the nerve. Preoperative imaging is crucial in cases of fracture of the hook of the
hamate. This can be diagnosed with radiographs; however, adequate imaging can be challenging, even with
carpal tunnel view radiographs. In those cases, a CT scan is the best imaging modality for fracture. Alternatively,
MRI can be useful in evaluating for ganglion cysts or other masses within Guyon's canal. In manual laborers who
sustain repetitive impacts or trauma to the volar ulnar wrist, a careful vascular examination is critical to evaluate
for ulnar artery thrombosis or aneurysm, which can affect the ulnar nerve as well. This includes Allen's test and
Doppler examination.
Technique
A standard carpal tunnel incision can be utilized, elevating a large ulnar flap. Alternatively, the skin is incised
along the radial aspect of the flexor carpi ulnaris (FCU) and extended distally, zig-zagging across the wrist flexion
crease, and extending distally into the palm along the ulnar border of the ring finger to the hook of the hamate.
The nerve is identified proximally, where it lies immediately radial and deep to the FCU. The ulnar artery can be
identified radial to the nerve. The nerve is then followed from proximal to distal. At the palm, the overlying palmar
fascia is released, and the volar carpal ligament (which forms the roof of Guyon's canal) is identified and divided.
The nerve is then followed distally as it travels superficial to the flexor retinaculum and between the pisiform and
hook of the hamate. Just proximal to the hook of the hamate, the nerve divides into the branch to the hypothenar
muscles, the deep motor branch, and the superficial sensory branches. The sensory branch provides innervation
to the palmaris brevis muscle and sensation to the small finger and the ulnar half of the ring finger. The deep
motor branch arises from the ulnar aspect of the nerve, diving deep to the continuation of the ulnar nerve, and
then wraps around the distal aspect of the hook of the hamate as it travels from ulnar to radial across the palm to
innervate the interossei, the ulnar two lumbricals, the adductor pollicis, and half the flexor pollicis brevis.
P.14
FIGURE 2-5 Zones of compression of the ulnar nerve at Guyon's canal. Compression in zone 1 will cause both
motor and sensory changes. Compression in zone 2 will cause isolated motor changes, sparing sensation,
whereas zone 3 compression will cause only numbness without loss of motor function.
Compression of the ulnar nerve can occur either proximal to the bifurcation of the ulnar nerve or distally and can
cause a mixed, pure motor, or pure sensory deficit depending on the portion of the nerve affected by the
compression. Zone 1 consists of the ulnar nerve proximal to its bifurcation; compression here results in mixed
motor and sensory deficits. Zone 2 is compression of the deep motor branch distal to its bifurcation; sensation is
spared when the nerve is compressed here. In situations such as this, it is critical to make sure the deep motor
branch has been specifically identified and fully decompressed during surgery. Compression of the ulnar nerve in
zone 3 causes pure sensory deficits, as only the superficial branch is affected, distal to the takeoff of the deep
motor branch (Fig. 2-5).
After the volar carpal ligament is released and the nerve mobilized, the floor of the canal should be inspected for
space occupying lesions such as ganglion cysts, which are commonly encountered.
Pearls and Pitfalls

Differentiating ulnar neuropathy at the elbow from ulnar neuropathy at the wrist is critical. Discussion with the
patient about activities that bring about symptoms and provocative physical examination findings can greatly aid
in making an accurate diagnosis. Diminished sensation of the dorsal ulnar hand is strongly indicative of more
proximal nerve compression; however, normal dorsal hand sensation does not rule out proximal ulnar nerve
compression.
I find that identification of the ulnar nerve is most predictable and straightforward by identifying the nerve in the
distal forearm radial to the FCU and then following the nerve distally. To follow the nerve distally to its branch
point, a significant amount of dissection of the overlying hypothenar musculature may be needed to both free the
nerve and adequately visualize the terminal branches.
Identification of the deep motor branch can be difficult, and must be definitively located and decompressed in
situations of intrinsic weakness. Failure to do so is a common reason for failed Guyon's decompression. The
motor branch should be seen diving deep to the nerve and wrapping around the distal aspect of the hook of the
hamate before traversing the palm. Care must be taken to ensure that you are not being fooled by branches to
the hypothenar musculature.
WAGNER APPROACH
Indications
First described by Wagner in 1950, the thumb carpometacarpal (CMC) joint can be exposed from a volar
approach. This can be used to reduce and stabilize fractures of the base of the first metacarpal (Bennett's
or Rolando's), or for ligament reconstruction with or without trapezium excision for CMC instability or
arthritis, respectively.
P.15
Technique
The incision for the Wagner approach runs along the junction of the palmar and glabrous skin, extending distally
between the abductor pollicis longus and the thenar musculature and stopping proximally radial to the FCR. The
terminal branches of the superficial radial sensory nerve will cross the radial aspect of the incision, and the
palmar cutaneous branch of the median nerve is found at the ulnar aspect of the incision; these must be
protected to prevent neuroma formation.
After the skin is incised and the cutaneous nerves are identified, the edge of the thenar musculature is identified
at the radial aspect of the first metacarpal. The radial border of the fascia is incised, and the muscle fibers are
elevated subperiosteally from radial to ulnar off of the joint capsule. By staying deep to the muscle, the overlying
neurovascular structures are avoided.
Once the joint capsule is exposed, it can be incised and the base of the metacarpal and the trapezium are
exposed. At this point, any fracture can be reduced, or the trapezium excised, depending on the surgical goal. If
CMC joint stabilization is the desired outcome, the radial half of the FCR can be harvested and utilized for
reconstruction of the intermetacarpal ligament.
Pearls and Pitfalls

Care must be taken to avoid injury to the superficial radial sensory nerve branches and the palmar cutaneous
branch of the median nerve, which lies just ulnar to the FCR tendon, and is at the proximal ulnar aspect of the
incision (Fig. 2-6).
FIGURE 2-6 Incision for the Wagner approach to the thumb CMC joint. Care must be taken to protect the
crossing branches of the superficial radial sensory nerve (dotted lines). At the ulnar aspect of the incision, the
palmar cutaneous branch of the median nerve will be encountered (see Fig. 2-2). (From Catalano LW, Zlotolow
DA, Lafer MP, et al.: Surgical exposures of the hand and wrist. J Am Acad Orthop Surg 2: 48-57, 2012.)
DEEP PALMAR SPACE INFECTIONS

There are three potential spaces within the palm that can become infected, resulting in deep space abscesses
that require operative drainage (Fig. 2-7). These are the thenar space, the hypothenar space, and the midpalmar
space. Infections are usually the result of direct penetrating trauma into the space. However, thenar infections
can result from direct extension of pyogenic flexor tenosynovitis of the index finger or deep infiltration of
subcutaneous infections. Midpalmar infections can result from proximal extension of long- or ring-finger pyogenic
flexor tenosynovitis. It is important to note that often the swelling with these conditions is dorsal, as the ligaments
and aponeuroses limit the amount of tissue extension that can occur palmarly. This can make diagnosis of these
infections challenging. Advanced imaging including ultrasound or MRI can be helpful in the setting of suspected
palmar space infection to identify and localize these abscesses (Table 2-1).
P.16
FIGURE 2-7 A: Demonstrates three deep potential spaces within the palm that can be the sites of purulent
infection requiring operative drainage: the thenar space, midpalmar space, and hypothenar space. Three deep
spaces within the palm can be the sites of purulent infection requiring operative drainage: the thenar space,
midpalmar space, and hypothenar space. B: Demonstrates an abscess within the thenar space. C: Shows an
abscess within the midpalmar space. (From Stevanovic MV, Sharpe F: Acute infections. In: Wolfe SW, Pederson
WC, Hotchkiss RN, et al., eds. Green's operative hand surgery. 6th ed. Philadelphia, PA: Elsevier, 2011.)
TABLE 2-1 Summary of Deep Space Infections Within the Palm
Deep Hand
Space Borders Presentation Surgical Points
Thenar Dorsal: adductor pollicis; Thenar and first webspace Palmar, dorsal, or two-
volar: index flexor swelling, thumb abduction incision approaches.
tendons; ulnar: vertical with painful adduction or Dorsal incision
midpalmar septum; opposition, pantaloon- perpendicular to first
radial: adductor pollicis shaped abscess if webspace to minimize
insertion at P1 of thumb involvement of first dorsal webspace contracture;
webspace through volar incision along
contiguous spread thenar crease
Midpalmar/deep Dorsal: middle and ring Loss of normal palmar Transverse incision in
palmar finger metacarpals and concavity with marked distal palmar crease;
second and third palm tenderness, painful curvilinear incision
interossei; volar: flexor passive motion of middle along thenar crease
tendons and lumbricals; and ring fingers;
ulnar: hypothenar substantial dorsal swelling
muscles; radial: vertical may be present
midpalmar septum
Hypothenar Dorsal: small finger Painful swelling over the Longitudinal incision
metacarpal; volar: palmar hypothenar eminence. along radial border of
aponeurosis and Limited palmar swelling small finger
hypothenar muscle beyond this area
fascia; ulnar: hypothenar
musculature; radial:
hypothenar septum
Adapted from Osterman M, Draeger R, Stern P: Acute hand infections. J Hand Surg Am 39(8): 1628-
1635, 2014.
Drainage of Thenar Abscesses

The thenar space goes from the thenar eminence to the third metacarpal, with a deep boundary of the adductor
pollicis fascia. As it travels ulnarly, the thenar space runs deep to the flexor tendons of the index finger, which
form the palmar boundary of the area.
To approach the abscess in the thenar space, either a palmar or dorsal approach can be utilized (Fig. 2-8). An
incision in the dorsum of the first webspace, either transverse or longitudinal, can be used; however, care must
be used with a transverse incision, as scar contracture will lead to loss of radial abduction of the thumb. Once
the skin is incised, the interval between the first dorsal interosseous and the adductor pollicis is identified and
bluntly opened. Purulent material should be encountered at this point.
P.17
FIGURE 2-8 Incisions for drainage of a thenar space abscess. A: Palmar incision within the thenar crease. B:
Dorsal longitudinal incision for within the first webspace. Transverse incisions should be avoided to prevent
webspace contracture. (From Stevanovic MV, Sharpe F. Acute infections. In: Wolfe SW, Hotchkiss RN,
Pederson WC, et al., eds. Green's operative hand surgery. 6th ed. Philadelphia, PA: Elsevier, 2011.)
FIGURE 2-9 Incisions for drainage of midpalmar space abscesses. Care must be taken, as the digital nerves and
palmar arch are all in danger during this approach. A: Transverse incision in the distal palmar crease. B:
Combined transverse and longitudinal, which allows easy extension into the hypothenar space if necessary. C:
Longitudinal approach. (From Stevanovic MV, Sharpe F: Acute infections. In: Wolfe SW, Hotchkiss RN,
Pederson WC, et al., eds. Green's operative hand surgery. 6th ed. Philadelphia, PA: Elsevier, 2011.)
If a volar approach is preferred, a curvilinear incision can be made in the thenar crease. Care must be taken with
deep dissection, as the recurrent motor branch of the median nerve, the digital nerves to the index finger and
thumb, the digital arteries to the thumb and index fingers, and the princeps pollicis artery are all within the
operative field and in danger of iatrogenic injury. Once the skin is incised, blunt dissection is carried toward the
adductor pollicis. The recurrent motor branch is very close, and particular care must be taken at this point.
Alternatively, the flexors to the index finger can be identified, and just radial to those tendons is the thenar space.
However, the risks of injury to the common digital arteries, common digital nerve, and recurrent motor branch
remain the same.
A combined volar-dorsal approach can be used, decompressing the adductor pollicis from the volar side and the
first dorsal interosseous from dorsally.
Drainage of Midpalmar Abscesses

The midpalmar space occurs in the midpalm between the thenar and hypothenar musculature, deep to the flexor
tendons of the long, ring, and small fingers, and palmar to the metacarpals and interossei. The midpalmar space
is typically approached volarly. The flexor tendons of the ring finger mark the ulnar border of the midpalmar
space and are a predictable landmark to find the abscess. Either an oblique incision or an L-shaped incision can
be made across the proximal palmar flexion crease and then extended proximally along the radial border of the
ring finger (Fig. 2-9). The flexor tendons are identified distally and followed proximally, taking care to find and
protect the superficial palmar arch and digital nerves.
P.18
Drainage of Hypothenar Abscesses
Hypothenar space abscesses are exceedingly rare. The hypothenar space is a small area from the hypothenar
septum to the hypothenar musculature. When encountered, the space can be drained through a longitudinal
incision along the fourth webspace, from the midpalm to just distal to the wrist flexion crease. The palmar fascia
is divided and the hypothenar musculature is identified. Once the fascia of the hypothenar muscles is opened,
purulence is encountered and can be irrigated. By staying superficial to this area, neurovascular structures are
avoided.
COMPLICATIONS/RESULTS/POSTOPERATIVE MANAGEMENT
Please see Chapter 4 for detailed discussion of the complications, results, and postoperative management of
deep space infections of the hand.
CONCLUSION
The complex anatomy of the hand challenges even the most experienced upper extremity surgeon. Detailed
understanding of this anatomy and the surgical approaches outlined here and in other chapters allow for
thoughtful and safe exposure for completion of the entire spectrum of hand surgery. The surgeon
specializing in hand and upper extremity must be facile with numerous surgical approaches to achieve
success in managing the full breadth of pathology encountered.
REFERENCES
1. Sacks JM, Kuo YR, Wollstein R, et al.: Anatomical relationships among the median nerve thenar branch,
superficial palmar arch, and transverse carpal ligament. Plast Reconstr Surg 120: 713-718, 2007.
2. Green DP, Morgan JP: Correlation between muscle morphology of the transverse carpal ligament and
branching pattern of the motor branch of median nerve. J Hand Surg Am 33: 1505-1511, 2008.
3. Al-Qattan MM: Variations in the course of the thenar motor branch of the median nerve and their
relationship to the hypertrophic muscle overlying the transverse carpal ligament. J Hand Surg Am 35: 1820-
1824, 2010.
4. Lourie GM, Gaston RG, Peljovich AE, et al.: Anomalous thenar musculature associated with aberrant
median nerve motor branch take-off: an anatomic and clinical study. Duke Orthop J 2: 18-22, 2012.
5. Gwathmey FW, Brunton LM, Pensy RA, et al.: Volar plate osteosynthesis of distal radius fractures with
concurrent prophylactic carpal tunnel release using a hybrid flexor carpi radialis approach. J Hand Surg Am
35: 1082-1088, 2010.
6. Pensy RA, Brunton LM, Parks, BG, et al.: Single-incision extensile volar approach to the distal radius and
concurrent carpal tunnel release: cadaveric study. J Hand Surg Am 35: 217-222, 2010.
7. Romeo P, D'Agostino MC, Lazzerini A, et al.: Extracorporeal shock wave therapy in pillar pain after carpal
tunnel release: a preliminary study. Ultrasound Med Biol 37: 1603-1608, 2011.
8. Grandizio LC, Beck JD, Rutter MR, et al.: The incidence of trigger digit after carpal tunnel release in
diabetic and nondiabetic patients. J Hand Surg Am 39: 280-285, 2014.
9. Lee SK, Bae KE, Choy WS: The relationship of trigger finger and flexor tendon volar migration after carpal
tunnel release. J Hand Surg (Eur Vol) 39: 694-698, 2014.
10. Karalezli N, Kutahya H, Gulec A, et al.: Transverse carpal ligament and forearm fascia release for the
treatment of carpal tunnel syndrome change the entrance angle of flexor tendons to the A1 pulley: the
relationship between carpal tunnel surgery and trigger finger occurrence. Sci World J 2013: 630617, 2013.
RECOMMENDED READING
Catalano LW, Zlotolow DA, Lafer MP, et al.: Surgical exposures of the hand and wrist. J Am Acad Orthop
Surg 2: 48-57, 2012.
Franko OI, Abrams RA: Hand infections. Orthop Clin North Am 44: 625-634, 2013.
Mackinnon SE, Novak CB: Compression neuropathies. In: Wolfe SW, ed.: Green's operative hand surgery.
6th ed. Philadelphia, PA: Elsevier, 2011: 41-84.
Osterman M, Draeger R, Stern P: Acute hand infections. J Hand Surg Am 39(8): 1628-1635, 2014.
Stevanovic MV, Sharpe F: Acute infections. In: Wolfe SW, Pederson WC, Hotchkiss RN, et al., eds. Green's
operative hand surgery. 6th ed. Philadelphia, PA: Elsevier, 2011: 41-84.
Chapter 3
Wide Awake Surgery on the Hand
Donald Lalonde
INDICATIONS
I began practice as a hand surgeon at the end of 1984. I learned in my training years that surgeons needed
a tourniquet to perform good hand surgery. We now know that is not true. All that we need to perform even
better, less expensive, and safer surgery is to inject lidocaine and epinephrine wherever we are going to
dissect (1). We do not need the tourniquet and its associated sedation to get great results.
WALANT (wide awake local anesthesia no tourniquet) hand surgery is applicable to 95% of all hand
operations. This chapter will enable the surgeon to get started in this approach.
CONTRAINDICATIONS
Patients who are not able to tolerate local anesthesia at the dentist
Surgeons who do not like to talk to patients during the surgery
Operations where a little blood in the field really is a problem (giant cell tumor, vascular malformations,
sarcomas, etc.)
Mangled hands
Excessively long operations such as multiple finger replantations
PREOPERATIVE PREPARATION
Office Advice for Patients
Explain that their hand operation will be a little like a visit to the dentist for a minor procedure. No preoperative
testing or fasting is required as lidocaine and epinephrine are the only administered medications, just like at the
dentist. They will be able to get up and leave right after the surgery with no nausea or uncomfortable sequelae or
inconveniences of sedation. They will not need to suffer the discomfort of the tourniquet.
In the office consultation, we also tell them that putting in the local anesthesia is like baking a cake. After we put
it in the oven, we need to give it at least a half an hour to “bake.” We tell them to bring a book or music, as they
will have to wait a while after we inject the local anesthesia.
Plan to Inject Two to Three Carpal Tunnels/Trigger Fingers Before You Do the First Case
It takes an average of 26 minutes for 1:100,000 epinephrine to reach maximal vasoconstriction (2). Inject two to
three patients before taking the first one into the operating room.
It only takes an average of 5 minutes to inject local anesthesia for carpal tunnel surgery so that the patient
consistently only feels the first poke of a 27-gauge needle (3). We inject them on stretchers in the preoperative
holding area, or in the postoperative anesthetic care unit.
P.20
The Occasional Patient Will Get Vasovagal So Inject Patients Lying Down
Fainting happens because of a decrease in cerebral blood flow. The body's response forces the patient to lie
down by fainting to increase the blood flow with gravity. More patients will faint sitting up than lying down, but
they can faint lying down as well. If they do faint, it can look like a seizure with patients going stiff and eyes
rolling back. We have all seen this with the occasional cast or dressing change.
You will get warning signs before the patient actually faints. The patient will tell you that he or she is not feeling
well, that the patient thinks he or she may be sick or will throw up, or that he or she is feeling really hot. When
you look at the patient, you may see perioral pallor, or paleness between the eyes, upper nose, and glabella.
When you see or hear the warning signs, get more blood to the head with the following five maneuvers, and
patients will feel better in less than 5 minutes:
Put your hand under the knees and lift them up.
Tell the patient to keep the knees and hips flexed to get blood from the thighs to the brain.
Take the pillow out from under the head and put it under the feet.
Put the head of the stretcher down (Trendelenburg)
Keep them in this position for at least 5 to 10 minutes or they will do it again if you sit them up too soon.
Always Warn Patients That They May Get an Epinephrine “Rush”

After you inject, always warn patients that they “may feel nervous or shaky” like “they may feel if they drank too
much coffee.” Tell them that this is a normal reaction to a little adrenaline in the numbing medicine and that the
shaky feeling will go away in half an hour or so if they get it.
If patients are not warned about it, fear of the unknown will add to unnecessary concern. They may even walk
away feeling that they are allergic to the medication, which they are not.
TECHNIQUE
Lidocaine Versus Bupivacaine
The author prefers to only use lidocaine with epinephrine. The two main reasons are the following. Firstly, these
two medications have an incredibly good safety record in their 65 years of use with no monitoring in dental
offices (4). Secondly, although bupivacaine pain relief dose last longer than lidocaine, bupivacaine and
ropivacaine are more cardiotoxic than lidocaine. Annoying bupivacaine numbness to touch and pressure lasts
twice as long (30 hours) as the pain anesthesia (15 hours) (5). This is why patients sometimes complain that
their finger is still numb but it hurts 20 hours after bupivacaine block.
Dosage Limit of Lidocaine With Epinephrine

We know that the 7 mg/kg maximum lidocaine with epinephrine rule is extremely safe because 35 mg/kg has
been shown to produce safe blood levels of lidocaine in liposuction (6). The author therefore feels comfortable
without monitoring unless the patient has severe preexisting cardiac challenges. In these situations, the
concentration of epinephrine can be reduced to 1:400,000 or even 1:1,000,000 with good effect (7). High-risk
patients can be monitored.
In order to stay below 7 mg/kg, the author uses up to 50 mL of 1% lidocaine with 1:100,000 epinephrine for most
70-kg patients. When 50 to 100 mL of volume of local anesthetic is required, the basic 50 mL can be diluted with
50 mL of saline to provide 1/2% lidocaine with 1:200,000 epinephrine. If 100 to 200 mL of volume is required for
big forearm cases, add 150 mL of saline to the basic 50 mL of 1% lidocaine with 1:100,000 epinephrine to make
1/4% lidocaine with 1:400,000 epinephrine for good anesthesia and visualization. The only problem with dilute
solutions is that the lidocaine and the epinephrine both take a little longer to achieve maximal effect and do not
last quite as long.
PEARLS AND PITFALLS

1% lidocaine with 1:100,000 epinephrine will provide anesthesia and vasoconstriction up to 4 hours after
injection.
Use a 27-gauge needle and inject slowly. Palpate at least 1 cm of local anesthesia ahead of the sharp needle
tip at all times to avoid pain.
P.21
Inject the patients outside of the operating room lying down to allow the lidocaine and epinephrine adequate
time to numb the skin and nerves, and to permit maximal epinephrine vasoconstriction.
It is always better to inject too much local anesthesia than to not inject enough.
Always have at least 1 cm of visible or palpable local anesthesia beyond wherever dissection or K-wire
insertion will occur.
We add bupivacaine if the case is a very big forearm and in complex cases possibly lasting 3 hours or more.
The cautery will not be required for most cases. There is no letdown bleeding from the tourniquet because
there is no tourniquet. Most bleeders dry up before the skin is closed.
Epinephrine is very helpful in patients on anticoagulation. The vasoconstriction decreases the bleeding. There
is no letdown bleeding because there is no tourniquet.
The dosage and location of local anesthesia injection for other operations than those listed below have been
published (8).
Carpal Tunnel Anesthesia

Inject 20 mL of 1% lidocaine with 1:100,000 epinephrine and 2.0 mL of 8.4% bicarbonate (9). Inject 2 mL beneath
the skin just proximal to the wrist crease and 5 mm ulnar to the median nerve to avoid lacerating it. Inject 8 mL
just beneath the radial forearm fascia to numb the median nerve. Inject the remainder under the skin under the
hand incision. Aim to get at least 1 cm of palpable, visible local anesthetic on either side of the incision. It takes
more than 30 minutes for the median nerve to achieve peak numbness and the same time for epinephrine
maximal vasoconstriction to occur as described above. That is why we inject two to three patients before we
operate on the first one (Fig. 3-1).
Inject 5 mL of 1% lidocaine with 1:100,000 epinephrine and 1.5 mL of 8.4% bicarbonate under the forearm fascia
and an additional 5 mL in the fat under the skin incision.
FIGURE 3-1 Local anesthesia for carpal tunnel surgery injection.
P.22
Trigger Finger
Inject 4 mL of 1% lidocaine with 1:100,000 epinephrine and 0.4 mL of 8.4% bicarbonate in the center of the
trigger finger incision just below the fat. There is no need to inject into the sheath. Sheath injections are painful.
The local anesthesia will diffuse into the sheath if given enough time to diffuse.
Flexor Tendon Repair or Dupuytren's Palmar Fasciectomy Anesthesia

Inject 10 mL of 1% lidocaine with 1:100,000 epinephrine and 1.0 mL of 8.4% bicarbonate in the palm 1 cm
proximal to where you plan to dissect (10). Allow the local to numb the nerves for 30 minutes. Then inject another
4 mL into the distal palm and 2 mL into the proximal and middle phalanges. Inject the local just beneath the skin
in the fat between the digital nerves. An additional 1 mL can be injected into the proximal midline subcutaneous
fat of the distal phalanx if dissection will occur there as in a zone 1 flexor tendon injury (see Figs. 3-2 and 3-3).
FIGURE 3-2 Local anesthesia for flexor tendon repair or Dupuytren's contracture surgery. Inject 10 mL of 1%
lidocaine with 1:100,000 epinephrine and 1.0 mL of 8.4% bicarbonate in the palm 1 cm proximal to where you
plan to dissect. Wait 30 or more minutes for the distal nerves to get numb and then inject as in Figure 3-3.
FIGURE 3-3 Local anesthesia for flexor tendon repair or Dupuytren's contracture surgery. Now that the distal
nerves are numb, inject another 4 mL more distally into the palm and 2 mL into the proximal and middle
phalanges. Inject the local just beneath the skin in the fat between the digital nerves. An additional 1 mL can be
injected into the proximal midline subcutaneous fat of the distal phalanx if dissection will occur there as in a zone
1 flexor tendon injury.
P.23
Extensor Indicis to Extensor Pollicis Longus Tendon Transfer
Inject 30 mL of 1% lidocaine with 1:100,000 epinephrine and 3.0 mL of 8.4% bicarbonate wherever you will
dissect in the thumb, index finger base, and hand (11).
Wrist or Forearm Multiple Tendon Lacerations

Inject a large volume of dilute local anesthesia (100 to 150 mL of saline + 50 mL of 1% lidocaine with 1:100,000
epinephrine + 5 mL of 8.4% bicarbonate) at least 2 cm beyond any area where you may need to dissect to find
the proximal and distal ends of the tendons and nerves. Always make sure to have more instead of not enough
local anesthesia to avoid any pain during the surgery. After the skin incision, find the proximal ends of large
nerves without grasping them. Inject an additional 10 mL around the proximal nerve stumps.
Trapeziectomy or LRTI
Inject 40 mL of 0.5% lidocaine with 1:200,000 epinephrine and 2.0 mL of 8.4% bicarbonate in the radial side of
the hand. Imagine that this is an extravascular Bier block, but only where you need it. Start on the proximal part
of the incision and inject 10 mL in the subcutaneous fat without moving the needle. Move the needle slowly, and
work your way around the trapezium, first volarly and then dorsally. Make sure to bathe the median nerve with
local in the process. Inject another 20 mL of the same mixture from proximal to distal over the flexor carpi radialis
tendon if you will use this tendon to perform an LRTI. The last injection is 5 mL of the local into the joint after
distracting the thumb. After making the skin incision and exposing the joint capsule, inject a further 5 mL into the
joint during the surgery.
POSTOPERATIVE MANAGEMENT
Complications
How to Inject Phentolamine to Reverse Epinephrine Vasoconstriction in the Finger Dogma that
epinephrine should never be injected in the finger dominated medical literature from the 1940s until the
2000s. There are still those who believe the myth in 2014. Ample evidence outlined below in bullets has
disproved the myth. I have never had to rescue a white finger from epinephrine vasoconstriction, but I have
demonstrated phentolamine rescue to many visitors. Surgeons should know how to rescue the finger with
phentolamine as a safety precaution. I encourage all surgeons to inject phentolamine at least once so you
are comfortable with doing this.
Procaine caused the finger deaths blamed on epinephrine before 1950 (12). Procaine became acidic to a
pH of 1 when it sat on the shelf in those days before expiry dates were mandated (13).
There are publications of thousands of finger injections with no necrosis and no requirement for
phentolamine rescue (14,15).
There are over 100 cases of high-dose 1:1,000 epinephrine (16,17) accidental injections into fingers. Not
one of those fingers injected with a dosage 100 times the concentration of epinephrine that we use
clinically for hemostasis actually died, even though many were not treated properly with phentolamine
reversal. If 1:1,000 epinephrine does not kill fingers, it is highly unlikely that 1:100,000 will ever kill a
finger. For accidental high-dose 1:1,000 epinephrine EpiPen injections, inject 1-mg phentolamine in 1 mL
of saline where the EpiPen is present in order to reverse the vasoconstriction (16).
The alpha-blocking rescue agent phentolamine reliably reverses epinephrine alpha-receptor
vasoconstriction at a dosage of 1 mg in 1 mL of saline in the human finger (level I evidence) (18). If the
surgeon is not comfortable with the color of the finger, he can expect phentolamine to reverse the
vasoconstriction within 2 hours of injection.
Phentolamine lowers blood pressure at a dosage of 3 mg to 5 mg intravenously (19). If the epinephrine has
been injected diffusely in the hand such as in flexor tendon repair or with palmar fasciectomy, inject 1 mg of
phentolamine in 5 to 10 mL of saline throughout the wound edges where the epinephrine was injected.
P.24
REFERENCES
1. Lalonde DH, Martin A: Epinephrine in local anesthesia in finger and hand surgery: the case for wide-
awake anesthesia. J Am Acad Orthop Surg 21(8): 443, 2013.
2. McKee DE, Lalonde DH, Thoma A, et al.: Optimal time delay between epinephrine injection and incision to
minimize bleeding. Plast Reconstr Surg 31(4): 811, 2013.
3. Lalonde DH: “Hole-in-one” local anesthesia for wide awake carpal tunnel surgery. Plast Reconstr Surg
126(5): 1642-1644, 2010.
4. Jeske AH: Xylocaine: 50 years of clinical service to dentistry. Tex Dent J 115(5): 9-13, 1998.
5. Calder K, Chung B, O'Brien C, et al.: Bupivacaine digital blocks: how long is the pain relief and
temperature elevation? Plast Reconstr Surg 131(5): 1098, 2013.
6. Burk RW III, Guzman-Stein G, Vasconez LO: Lidocaine and epinephrine levels in tumescent technique
liposuction. Plast Reconstr Surg 97(7): 1379-1384, 1996.
7. Prasetyono TO, Biben JA: One-per-mil tumescent technique for upper extremity surgeries: broadening the
indication. J Hand Surg Am 39(1): 3-12, 2014.
8. Lalonde DH, Wong A: Dosage of local anesthesia in wide awake hand surgery. J Hand Surg 38A(10):
2025, 2013.
9. Farhangkhoee H, Lalonde J, Lalonde DH: Teaching medical students and residents how to inject local
anesthesia almost painlessly. Can J Plast Surg 20(3): 169, 2012.
10. Lalonde DH, Kozin S: Tendon disorders of the hand. Plast Reconstr Surg 128(1): 1e-14e, 2011.
11. Bezuhly M, Sparkes GL, Higgins A, et al.: Immediate thumb extension following extensor indicis proprius
to extensor pollicis longus tendon transfer using the wide awake approach. Plast Reconstr Surg 119(5):
1507, 2007.
12. Thomson CJ, Lalonde DH, Denkler KA: A critical look at the evidence for and against elective
epinephrine use in the finger. Plast Reconstr Surg 119(1): 260, 2007.
13. Food and Drug Administration: Warning-procaine solution. JAMA 138: 599, 1948.
14. Lalonde DH, Bell M, Benoit P: A multicenter prospective study of 3,110 consecutive cases of elective
epinephrine use in the fingers and hand: the Dalhousie project clinical phase. J Hand Surg 30(5): 1061,
2005.
15. Chowdhry S, Seidenstricker L, Cooney DS, et al.: Do not use epinephrine in digital blocks: myth or truth?
Part II. A retrospective review of 1111 cases. Plast Reconstr Surg 126(6): 2031-2034, 2010.
16. Fitzcharles-Bowe C, Denkler KA, Lalonde DH: Finger injection with high-dose (1:1000) epinephrine: does
it cause finger necrosis and should it be treated? HAND 2(1): 5, 2007.
17. Muck AE, Bebarta VS, Borys DJ: Six years of epinephrine digital injections: absence of significant local or
systemic effects. Ann Emerg Med 56(3): 270-274, 2010.
18. Nodwell T, Lalonde DH: How long does it take phentolamine to reverse adrenaline-induced
vasoconstriction in the finger and hand? A prospective randomized blinded study: the Dalhousie project
experimental phase Can J Plast Surg 11(4): 187, 2003.
19. Canadian Pharmacists Association Compendium of Pharmaceuticals and Specialties 2000:1405.

Chapter 4
Infections of the Hand
Patrick G. Marinello
Steven D. Maschke
GENERAL CONSIDERATIONS
Encountering infections of the hand is relatively common for most hand surgeons, and these range from
relatively benign to devastating. Prompt diagnosis and treatment should be the priority for all infections of the
hand. Primary care and/or emergency medicine physicians oftentimes initially see these patients and are
challenged with not only making the correct initial diagnosis but also knowing when to refer to a higher level of
specialty care. How effective this channel of communication determines the timing and appropriateness of both
diagnosis and treatment, which can greatly alter clinical outcomes. The hand surgeon is charged with
determining the appropriateness of continued nonoperative care versus the need for operative intervention. The
history, physical examination, and knowledge of hand anatomy with its many potential spaces, in conjunction
with advanced imaging studies when indicated, guide the surgeon in making the correct diagnosis and determine
appropriate management.
FLEXOR TENOSYNOVITIS
Indications/Contraindications
The volar surface of the hand and fingers frequently comes in contact with potentially harmful objects and
environments. The flexor tendons and surrounding sheath are in within millimeters of the skin, making them
susceptible to penetration from even minor trauma. Unlike a localized infection in the subcutaneous tissue,
inoculation of the flexor tendon sheath provides the bacteria with a path of low resistance to migrate proximally
and distally. An innocent-looking puncture wound has the ability to deliver a potentially devastating bacterial
organism throughout the tendon sheath of a digit with potential proximal spread into the palm. Although most
infections are a result of direct seeding with penetrating trauma, immunocompromised hosts such as patients
with poorly controlled diabetes, malnutrition, and HIV are susceptible to hematogenous infections. Healthy
patients presenting with flexor tenosynovitis (FTS) without antecedent trauma should have gonococcal infection
in the differential diagnosis.
In 1943, Kanavel described four cardinal signs of FTS: (a) flexed posture of the finger, (b) fusiform swelling of the
finger, (c) tenderness over the entire course of the flexor tendon sheath, and (d) pain on passive extension of the
finger (added later). The bacterial infection causes local edema of the tendon, sheath, and surrounding soft
tissues. The vincular and intratendinous vascular supply and nutritional support of the tendon become
compromised from the elevated pressure within the sheath with the end result being potential tendon necrosis
and rupture. Additionally, the gliding mechanism is quickly compromised leading to stiffness and scarring within
the tendon sheath.
Patients either will present with a known injury with progressive pain and swelling or may not recall an
antecedent event prior to the onset of symptoms. A high index of suspicion for FTS is paramount and should
prompt urgent consultation and evaluation by a hand specialist. If
P.26
early in the disease process, a trial of antibiotics, immobilization, and elevation can be tried for a period of 12 to
24 hours. This should be administered in a hospital observation unit where the patient can be closely monitored.
Consultation with an infectious disease specialist can be helpful in selecting appropriate empiric antibiotic
therapy targeted at the most common pathogens and taking hospital-specific antibiotic resistance into account. If
no improvement is seen during this short time frame, the patient is urgently brought to the operating room for a
proper irrigation and debridement.
The long-term sequela of inadequate or delayed treatment of FTS can be devastating, and this condition must
be treated aggressively. Functional loss of the affected digits due to stiffness from adhesions, possible tendon
necrosis/rupture, as well as spread of the infection more proximally to potential spaces of the hand are all
potential consequences of poor management. Severe cases of FTS may lead to digital amputation. All hand
surgeons must have a low threshold to perform an expeditious and complete irrigation and debridement in the
operating room. Generally, the risk of inaction is much higher for the patient than are the potential complications
from surgical intervention.
Pre-Op Planning and Anatomy

The clinical history of a penetrating injury or spontaneous swelling in the digit of an immunocompromised patient
along with positive Kanavel's signs should be sufficient to make the diagnosis of FTS. All digits need to be
examined carefully as more than one finger may be involved. Also, careful evaluation of the palm and wrist for
deep space infection or communication between the fingers is critical (Fig. 4-1).
Knowledge of the anatomy of the flexor tendon sheath aids in understanding where the infection may spread. In
the middle three digits (index, long, and ring finger), the tendon sheaths run from the A1 pulley to the FDP
insertion. For the thumb and the little finger, the tendon sheaths extend more proximally to the radial and ulnar
bursas, respectively. If the infection penetrates the tendon sheath of the thumb or small finger, it has the potential
to spread into the thenar or hypothenar spaces. Communication at the level of the wrist occurs in a potential
space between the flexor digitorum profundus tendons and the fascia of the pronator quadratus muscle. Infection
in this space, known as Parona's space, leads to a “horseshoe” abscess. Tenderness and swelling in Parona's
space should always be evaluated, and when present, surgical decompression proximal to the wrist flexion
crease is indicated.
Standard orthogonal view x-ray examination of the affected hand is recommended for evaluation of bony
involvement or associated foreign bodies. Advanced imaging with an MRI or ultrasound is not indicated when the
clinical diagnosis is clear but can be helpful when the diagnosis remains elusive. Laboratory evaluation is helpful.
Complete blood count (CBC), erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP) are useful
adjuncts to help confirm a diagnosis. However, it is not uncommon for the acute phase reactants to be normal in
the early
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stages of FTS. Trending laboratory values postoperatively can be useful to determine resolution of infection.
FIGURE 4-1 A: Note the fusiform swelling of this index finger with suppurative FTS. B: Although the involved
index finger is “semiflexed,” as described by Kanavel, note that the increased pressure within the tendon sheath
causes this finger to be relatively more extended than the flexion cascade of the adjacent fingers at rest.
Antibiotics are a critical part of the treatment for this condition. Unfortunately, in our personal experience, most
patients have received antibiotics prior to our consultation, and this may affect our ability to isolate the offending
organism and target our antibiotic regimen. If the patient is stable, it is our practice to hold antibiotic therapy until
after cultures have been obtained either via aspiration of the tendon sheath or intraoperatively.
Surgical Technique
The patient is placed supine on the operating table with the affected upper extremity on a hand table. A well-
padded proximal pneumatic tourniquet is applied on the upper arm. For cases of infection, general anesthesia is
typically used at our institution. In the acidic environment of an ongoing infection, local infiltrative anesthetic is
not as effective. Surgical loupes magnification and appropriate operating room lighting are beneficial.
The upper extremity is then prepped and draped in the usual sterile fashion. A preoperative surgical time-out is
performed verifying the correct patient, laterality, anatomic location of the surgery, allergies, preoperative
antibiotics (or if they are held), and the presence of necessary equipment and personal. The arm is gravity
exsanguinated, and the tourniquet is inflated to 250 mm Hg. No Esmarch bandage is used for exsanguination in
cases of infection to diminish risk of spread. We typically hold preoperative antibiotics, and the patient receives
them after cultures are obtained.
A midaxial incision is made centered on the PIP joint of the affected digit (Fig. 4-2). We incorporate the traumatic
wound when appropriate but will not alter our incision to include wounds away from the standard approach. The
incision is made on the side of the digit with the least contact. For the index, long, and ring fingers, the incision is
typically made on the ulnar side while the incision is made on the radial side for the small finger and thumb. The
midaxial incision is extended both proximally and distally as far as needed to allow safe and complete surgical
decompression. The neurovascular bundle is identified, dissected, retracted with the palmar flap, and protected
(Fig. 4-3). The flexor sheath is identified, and the A3 pulley is incised (Fig. 4-4). Specimens for Gram stain and
microbiology can be collected at this time. Careful but deliberate debridement of hypertrophic synovium is
completed at this time. If antibiotics were held, after collection of specimens for microbiology, broad-spectrum
antibiotic therapy can be initiated. In more severe infections or delayed treatment, larger incisions and multiple
windows into the flexor sheath may be required to accomplish adequate debridement.
Attention is then turned to the palm. A short Brunner incision at the MP flexion crease of the affected digit is
made, and blunt dissection down to the A1 pulley is completed (Fig. 4-5). The A1 pulley is incised, and
debridement is accomplished. After both proximal and distal debridement is completed, a no. 5 pediatric feeding
tube is passed into the flexor sheath from distal to proximal. Several liters of normal saline are flushed through
the sheath with the surgeon ensuring excellent egress. We then pass the feeding tube from proximal to distal and
irrigate several more liters of fluid.
FIGURE 4-2 Midaxial surgical approach. The midaxial incision passes through the center of rotation to the PIP
and DIP joints. This is approximately 2 to 3 mm dorsal to the midlateral line. The incision should be made on the
side of the digit with the least contact. (Reprinted with permission, Cleveland Clinic Center for Medical Art &
Photography © 2015. All Rights Reserved.)
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FIGURE 4-3 The plane of dissection in the digit reflects the neurovascular bundle with the palmar skin flap.
FIGURE 4-4 A: The A3 pulley is removed to gain access to the flexor tendons. It is critical that the A2 and A4
pulley remain intact. B: Clinical photo demonstrating that the flexor tendon sheath has been opened between the
A2 and A4 pulleys. Note the purulent exudate. (Part A Reprinted with permission, Cleveland Clinic Center for
Medical Art & Photography © 2015. All Rights Reserved.)
After through decompression and debridement, the tourniquet is deflated and hemostasis is achieved with bipolar
cautery. Both wounds are left open. If the severity of the infection warrants, a stay suture can be placed in the
proximal incision to facilitate drainage. Prior to leaving the OR, the digit should be inspected for PROM and good
capillary refill. We place Penrose drains in both the proximal and distal incisions to facilitate drainage. A bulky
sterile dressing is applied as well as a volar splint in the resting position. If there is no clinical response in the
initial 24 to 36 hours, a repeat debridement and irrigation with new cultures is undertaken in the operating room.
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FIGURE 4-5 A: Short Brunner incision at the MP flexion crease of the affected digit is made, and blunt dissection
down to the A1 pulley is completed. B: Clinical image showing irrigation of wound using irrigation tubing from
distal to proximal. (Part A Reprinted with permission, Cleveland Clinic Center for Medical Art & Photography ©
2015. All Rights Reserved.)
Post-Op Management
Admission to an inpatient nursing unit is mandatory after irrigation and debridement for FTS. The patient must
strictly elevate the affected extremity, and nursing and physician teams perform frequent neurovascular checks.
At our institution, a postoperative consultation with infectious disease is standard protocol. Initially, broad-
spectrum IV antibiotics (at our institution vancomycin and Zosyn) are started while operative cultures and
sensitivities are pending. In consultation with our infectious disease colleagues, we prepare the patient for
hospital discharge on either home going IV antibiotics or, depending on the organism, oral antibiotic therapy.
Antibiotics are continued until the infection is eradicated and will be influenced by pathogen, severity of infection,
and immune status of the patient.
Rehabilitation
Starting on the first postoperative day, the dressing is removed, and wound care as well as occupational hand
therapy (OT) is initiated. The hand therapist fashions a resting splint, evaluates the wounds, removes the drains,
and initiates edema control measures and aggressive range-of-motion exercises. With FTS, the main goal of
hand therapy after operative debridement is to regain and maintain as much motion as possible. Active assisted
digital range of motion is a critical part of the treatment (Fig. 4-6). Upon discharge, the patient will continue
frequent outpatient visits with OT for monitoring and continued progress with wound healing, edema control, and
motion.
The surgical wounds will heal by secondary intention. Sometimes, scar revision might be indicated, but proper
placement of surgical incisions will limit such revision surgery. The psychological effect of open wounds after
debridement of FTS can be a barrier for the patient taking an active role in his or her care and rehabilitation. The
hand surgeon and hand therapist can be very influential in educating the patients and helping them become
champions of their own recovery.
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FIGURE 4-6 Active range of motion 5 days after decompression and lavage of suppurative FTS of the long
finger.
Outcomes and Complications

There is tremendous variability as to the outcomes of FTS. Stiffness of the DIP and PIP joints is common
especially when therapy is delayed or the patient is noncompliant. Single organism early infections in a healthy
patient with expeditious and appropriate management will often lead to full motion of the digit within 1 to 2 weeks
and healing of the surgical scar shortly thereafter. In contrast, delayed presentation of a polymicrobial infection in
an immunocompromised host may fail even repeat surgical debridement and ultimately require amputation.
Severity of infection, timing, and host factors all convene to affect long-term outcomes. Host factors negatively
impacting outcome include age greater than 43, diabetes mellitus, renal failure, and peripheral vascular disease.
Clinical factors indicating potential poor outcome include digital ischemia, subcutaneous purulence, and
polymicrobial infection. While the treating physician cannot control the patient's health status upon presentation,
the surgeon can dictate how quickly definitive care is offered. In the earliest stages of FTS, a short course of
nonoperative treatment (elevation and antibiotics) is cautiously indicated, but no more than 12 to 24 hours should
elapse before more aggressive surgical treatment is provided. We only consider this course in mild cases with
very early symptoms and only 1 or 2 Kanavel's signs. Thorough debridement and irrigation, consultation with an
infectious disease colleague, and utilization of hand therapy all play a significant role in maximizing long-term
outcomes.
DEEP SPACE INFECTIONS

General Considerations
Deep space infections of the hand are uncommon, and the clinical presentation and diagnosis can be
challenging. Such infections arise from proximal spread of FTS or from primary inoculation of the hand through
penetrating trauma. The hand has three potential deep spaces: the thenar space, the hypothenar space, and the
midpalmar space (Fig. 4-7). Clinical presentation will often demonstrate
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dramatic swelling of the entire hand most evident dorsally as the tight volar fascia limits palmar swelling. All
patients will have exquisite tenderness to palpation over the involved space.
FIGURE 4-7 Medical illustration of the hypothenar, thenar, and midpalmar potential spaces. Also depicted are
the flexor tendon sheaths. (Reprinted with permission, Cleveland Clinic Center for Medical Art & Photography ©
2015. All Rights Reserved.)
FIGURE 4-8 Clinical picture depicting midpalmar space infection with loss of palmar concavity.
Thenar space infections are most common. The thenar eminence will be tense and quite tender to palpation.
The thumb will be held in an abducted posture, and attempted active or passive adduction will lead to significant
pain. Frequently, the purulence will track over the adductor pollicis and first dorsal interossei muscles leading to
a “collar button” abscess of the first web space.
Midpalmar space infections are less common and occur via penetrating trauma or proximal migration from FTS of
the long and ring fingers. Significant swelling of the entire hand is present with loss of the normal concavity of the
palm assuming a convex appearance (Fig. 4-8). We have seen median nerve compromise from infection in the
midpalmar space.
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Hypothenar infections are uncommon. They almost always occur via direct penetrating injury and will
demonstrate less overall swelling of the hand. Tenderness to palpation directly over the hypothenar space and a
high index of suspicion lead to appropriate diagnosis.
Advanced imaging is often beneficial to help arrive at the correct diagnosis and direct surgical management. The
patients we have managed have presented with dramatic swelling of the entire hand and pain limiting their ability
to localize the area of most significant pain. MRI is our preferred method of evaluation, but if timely access is not
available, ultrasound has shown benefit in localization and determining extent of infection.
There is not a role for nonoperative management of these infections. Once the correct diagnosis is obtained,
urgent operative management must be undertaken.
Surgical Technique
The surgical management of these infections is straightforward. We prefer to use volar approaches and design
our incisions to limit potential scar contracture. Most importantly, we avoid extending our incisions distally into the
web spaces. If our ability to decompress the abscess dorsally is limited, we prefer to make a separate dorsal
approach. The surgical approaches also place the neurovascular structures at risk and require careful dissection
and surgical technique. The infections lie deep in the hand with the dorsal boundary being the metacarpals and
intrinsic musculature. Again, careful evaluation for dorsal tracking is mandatory, and if limited by the volar
approach, a separate dorsal exposure is prudent. After complete irrigation and debridement, the wounds are left
open or loosely approximated with surgical drains or packing in place (Fig. 4-9). As with FTS, immediate
postoperative care consists of fabrication of a resting splint, wound care and soaks, edema control, and motion.
Antibiotics are managed in conjunction with our infectious disease colleagues and continued based on clinical
response.
FIGURE 4-9 A: Clinical photograph of palmar deep space infection from penetrating trauma. B: Extensile volar
surgical approach. C: Loosely approximated closure with surgical drain.
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Outcomes
As with FTS, outcome is dependent on host factors and time to surgical treatment. Due to the deeper nature
of the infection, it can make the clinical diagnosis more challenging, and delayed treatment is not
uncommon.
Stiffness and contractures are common following deep space infections but can be minimized by
appropriate surgical management and implementing an active motion therapy program. We believe active
motion is critical to encourage tendon gliding and joint motion and limit long-term complications. The unique
anatomy of the deep spaces of the hand can lead to complications secondary to treatment. Iatrogenic nerve
and vascular injuries occur secondary to altered anatomy and poor technique. Scar contracture is not
uncommon but can be avoided by thoughtful placement of surgical incisions. With prompt diagnosis and
appropriate surgical management, the vast majority of patients achieve full recovery and return to their
previous occupation.
HIGH-PRESSURE INJECTION
Presentation and Indications for Surgery
High-pressure injection injuries of the hand are relatively rare but potentially devastating injuries to the hand.
The patient is almost always a male industrial worker utilizing high-pressure tools. The injury is commonly found
in the nondominant hand and occurs accidentally when misusing
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or cleaning a malfunctioning piece of equipment. The real danger of these injuries is that the initial external injury
is typically not impressive. The patient as well as inexperienced healthcare providers can be fooled by the
benign appearance of the injury and may not initiate prompt tertiary referral.
FIGURE 4-10 A: Clinical photograph of puncture wound from highpressure injection injury from oil-based paint.
B,C: AP and lateral radiographs demonstrating foreign material.
The pressure associated with the injury greatly impacts the rate of digital amputation. For pressure less than
1,000 psi, the amputation rate is approximately 20%, while pressure greater than 1,000 psi is associated with an
amputation rate above 40%.
Overall amputation rate for high-pressure injuries is approximately 30%.
Organic solvents (paint, thinners, gasoline, diesel fuel) have much higher (approaching 40%) amputation rates,
while injuries due to water or air have a much better outcome. Fingers are more likely to be amputated than
injuries to the thumb and palm.
The key to successful outcome following these injuries is ensuring prompt treatment. Delayed debridement
beyond 6 hours from injury leads to an increased incidence of amputation. The exception to this is high-pressure
injuries from air or water. The amputation rate for these materials in the literature is 0%, and they can be treated
nonoperatively. Infection was found in approximately 40% of injuries and was polymicrobial in nature, and broad-
spectrum IV antibiotic coverage is crucial. Some have advocated steroid used in the acute setting. Theoretically,
the steroids can help modulate the inflammatory response. The use of this adjunctive therapy is controversial,
and no definitive consensus exists on its risks and benefits.
Radiographs are helpful and aid in defining the proximal extent of the injected material. We have encountered
patients with high-pressure injections at the distal tip of the finger with proximal tracking into the midforearm (Fig.
4-10).
Surgical Technique
As previously described, general anesthesia, standard supine positioning with a hand table, and gravity
exsanguinated tourniquet are utilized. In our opinion, the timing of surgery is most critical. Unlike surgery for FTS,
the surgical approach must provide wide exposure to allow access for complete removal of the injected material.
When designing our surgical incisions, we prefer midaxial incisions with extension into the palm and forearm as
indicated (Fig. 4-11). In our opinion, Brunertype exposures increase the risk of flap necrosis and long-term
complications.
After raising full-thickness flaps, the neurovascular structures are carefully dissected and protected. The injected
material is then meticulously removed with a combination of rongeur, curette, and/or any other instrument that is
effective. Removal is often painstakingly slow and requires patience and perseverance. Thorough irrigation with
normal saline is undertaken. The tourniquet is deflated, and capillary refill is confirmed. Management of the skin
is case dependent. In relatively minor cases, we will close the skin and initiate occupational therapy. In more
advanced cases, we will leave the wounds open and pack with saline-soaked gauze. In these cases, a planned
return to the operating room 36 to 48 hours later is undertaken for repeat evaluation, further debridement, and
loose approximation of the skin.
Postoperative management is similar to that for FTS and deep space infections. We continue antibiotics for 7 to
10 days and personally do not favor the use of corticosteroids. Hand therapy is critical for wound care, edema
control, and regaining motion.
FIGURE 4-11 A,B: Clinic photograph of midaxial approach for debridement of material from high-pressure
injection injury from oil-based paint.
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Management Considerations
For high-pressure injuries, organic solvents provide the most challenging conditions due to the nature and tissue
toxicity of the material. Debridement within 6 hours is the goal. Understanding the nature of the injury (timing,
material, and pressure involved) will allow the surgeon to appropriately inform the patient regarding risks and
long-term expectations. Hogan and Ruland reviewed 435 cases of high-pressure injection injury to the hand with
an overall amputation rate of 30%. Organic solvents, pressure above 1,000 psi, and delayed surgical
debridement (greater than 6 hours) all negatively impacted the rate of amputation. An amputation rate of 88%
was found for those injuries secondary to organic solvents and no operative intervention. These results need to
be discussed with patients upon presentation setting the stage for appropriate expectations. Pain and stiffness
are not uncommon following injury.
CONCLUSIONS
Prompt diagnosis and treatment of infections and high-pressure injuries in the hand are essential to
maximize the clinical outcomes and patient recovery. A low threshold should be maintained for operative
intervention, as irrigation and debridement is the mainstay of treatment. Collaboration with colleagues in
infectious disease and occupational therapy is invaluable to the long-term success and return of function in
these challenging cases.
RECOMMENDED READING
Abrams RA, Botte MJ: Hand infections: treatment recommendations for specific types. J Am Acad Orthop
Surg 4(4): 219-230, 1996.
Draeger RW, Bynum DK Jr: Flexor tendon sheath infections of the hand. J Am Acad Orthop Surg 20(6): 373-
382, 2012.
Hogan CJ, Ruland RT: High-pressure injection injuries to the upper extremity: a review of the literature. J
Orthop Trauma 20(7): 503-511, 2006.
Pappou IP, Deal DN: High-pressure injection injuries. J Hand Surg 37(11): 2404-2407, 2012.
Rosenwasser MP, Wei DH: High-pressure injection injuries to the hand. J Am Acad Orthop Surg 22(1): 38-
45, 2014.
Schnall SB, Vu-Rose T, Holtom PD, et al.: Tissue pressures in pyogenic flexor tenosynovitis of the finger. J
Bone Joint Surg [Br] 78(5): 793-795, 1996.
Sharma KS, Rao K, Hobson MI: Space of parona infections: experience in management and outcomes in a
regional hand centre. J Plast Reconstr Aesthet Surg 66(7): 968-972, 2013.
Chapter 5
Operative Treatment of Metacarpal Fractures
Lance A. Rettig
Thomas J. Graham
INDICATIONS/CONTRAINDICATIONS
The majority of isolated metacarpal fractures are effectively managed with closed reduction and splint
immobilization. However, a subset of metacarpal shaft or neck fractures cannot be reduced by closed means or
are unstable after reduction. For these fractures, operative treatment is a consideration or a requirement. Simple
extra-articular diaphyseal metacarpal fractures may be amenable to transcutaneous pin fixation or intramedullary
stabilization. If the fracture is not reducible by closed reduction, or if pin stabilization fails to maintain adequate
stability, open treatment is required. Indications for open reduction and internal fixation include open fractures,
injury to multiple metacarpals, intra-articular displacement, and fractures associated with significant soft-tissue
injury or segmental bone loss. The decision to consider operative stabilization may be influenced by age and
hand dominance along with vocational and avocational demands. Few true contraindications exist to operative
fixation of metacarpal fractures. Age is a consideration in young patients with open physis or elderly with severe
osteopenia.
PREOPERATIVE PLANNING
Physical examination should focus on assessing rotation, shortening, and angulation of the digit resulting from
the metacarpal fracture. The majority of metacarpal fractures can be adequately evaluated with plain film
radiographs. Anteroposterior, lateral, and oblique hand x-rays are important to help characterize the fracture and
define the metacarpal anatomy. A Brewerton view may be helpful in the evaluation of the fractures of the
metacarpal head. Semipronated or semisupinated oblique
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projections are of value when assessing injuries of the border rays, especially possible carpometacarpal (CMC)
fracture-dislocations. CT imaging of the hand may be beneficial in these instances to evaluate for concomitant
hamate injury or subluxation of the CMC joint.
SURGICAL TECHNIQUE
The operating room setup is standard for surgery of the hand. The patient is supine with the affected extremity
on a hand table. A padded pneumatic tourniquet encircles the proximal brachium. The anesthesia choices range
from local (wrist block) and regional (including axillary and Bier block) to general endotracheal anesthesia
regardless of closed versus open treatment. Prior to prepping and draping, it may be helpful to perform a
fluoroscopic examination of the metacarpal injury. Traction and manipulation of the involved ray under the
fluoroscan can provide information about fracture reduction and detail about the pathoanatomy. This step is
important in determining whether the fracture can be managed with closed reduction and pinning or by open
methods. Further defining the fracture in this manner may also assist in placement of the skin incision when open
treatment is indicated.
When an open approach is required, skin incisions are positioned slightly offset from the metacarpal to reduce
the risk of scarring of the extensor mechanism (Fig. 5-1). Following the skin incision, blunt dissection is
undertaken to identify branches of the superficial radial and ulnar nerves. Extreme caution should be undertaken
when approaching the most ulnar ray, particularly the more proximal aspect of the metacarpal. Careful handling
of the dorsal ulnar sensory nerve is critical in the approach to the small finger metacarpal. This is especially
important when performing intramedullary pinning (Fig. 5-2).
Exposure of the fracture is undertaken by incising the periosteum longitudinally. Subperiosteal dissection will
help define the plane of the injury. In cases of long oblique diaphyseal or comminuted segments, extreme care
should be undertaken to avoid additional compromise of the bone integrity. The fracture site is inspected and
irrigated to ensure that no intervening soft-tissue structures are blocking reduction. This step is particularly
important in cases of delayed treatment when scar or granulation tissue may impede anatomic restoration.
Maintenance of exposure is achieved with the use of self-retaining retractors and Hohmann- or Bennett-type
instruments.
Fracture reduction is undertaken by a combination of longitudinal traction and derotation. In certain cases,
realignment of the metacarpal may be facilitated by performing a Jahss maneuver. By positioning the MCP joint
in a flexed posture, the proximal phalanx can be used as a lever to assist with addressing rotational deformity. A
sharp tenaculum will assist with reduction and provisionally stabilize the fracture. Once anatomic reduction has
been achieved, Kirschner wires may also be utilized to temporarily stabilize the metacarpal. Clinical assessment
of digital alignment is assessed by passively positioning the digits into flexion to ensure there is no digital
overlap.
Implant selection is largely based on the plane and configuration of the fracture. Although each fracture has a
unique personality, there are some basic tenets to fixation of these injuries that exist.
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Implant choices include lag screw fixation alone or combined with plate stabilization. Plate fixation may be used in
compression or as a neutralization device. Other options not discussed in this chapter include wiring techniques
or external fixation.
FIGURE 5-1 Longitudinal incisions are offset from the fractured metacarpal in an effort to spare the extensor
tendon(s) from excessive scarring with contiguous skin and bone while preserving sufficient fracture exposure.
FIGURE 5-2 The diagram illustrates the course of the dorsal sensory branch of the ulnar nerve and its proximity
in the approach utilized for small finger metacarpal bouquet pinning. A retractor is placed deep to the extensor
carpi ulnaris and is retracted radially.
With indications established, the choice of operative fixation becomes the next consideration. For the purposes
of this chapter, fracture treatment will be divided into closed treatment with pin stabilization and open reduction
internal fixation.
CLOSED TREATMENT WITH PIN STABILIZATION

A myriad of configurations and techniques have been described for closed reduction and pinning of metacarpal
fractures. These have included cross-pinning, transverse pinning to an adjacent intact metacarpal,
intramedullary pinning, or combination of these patterns. Collateral recess pinning and bouquet pinning are
described because of the technical challenge inherent in these fixation methods and their unique utility.
Collateral Recess Pinning

This method is often utilized for reducible transverse diaphyseal fractures and metacarpal neck injuries. Fracture
extension into the collateral recess and degree of comminution may preclude the use of this technique in certain
cases. Provisional closed reduction of the fracture is performed. The metacarpophalangeal (MCP) joint of the
fractured metacarpal is flexed to 90 degrees. A 0.045-inch or 0.062-inch Kirschner pin is manually positioned
percutaneously onto the radial or ulnar collateral recess while maintaining the flexed posture of the MCP joint.
The initial pin placement is completed by feel or stereognosis (Fig. 5-3). Fluoroscopy is used to confirm
appropriate placement at the deepest concavity of the collateral recess. A lateral view is also completed to
evaluate the position of the wire in the sagittal plane.
Assessing initial pin position is critical to minimize the number of additional passes of the wire required to achieve
fixation. Once the pin has been manually positioned in the collateral recess, the driver is positioned over the
wire. The pin is captured at its flex point nearest the leading end of the Kirschner wire (Fig. 5-4A). The pin is then
advanced into the shoulder of the metacarpal
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while the appropriate angle is established. One must consider the relationship of the pin to the metacarpal in
both the sagittal and frontal planes prior to intramedullary placement of the wire. The Kirschner pin needs be
positioned collinear with the long axis of the metacarpal within the sagittal plane (Fig. 5-4B). Alignment in the
coronal plane requires that the pin be placed at an angle so that the leading edge of the wire crosses the
fracture site within the confines of the intramedullary canal.
FIGURE 5-3 A: The Kirschner pin is manually placed into the collateral recess with the metacarpophalangeal
joint of the fractured metacarpal flexed to 90 degrees. B: The smooth wire is placed at the deepest concavity of
the collateral recess.
FIGURE 5-4 A: After manual positioning of the Kirschner wire onto the collateral recess, the pin is captured at
the flex point nearing the leading edge of the smooth pin. The metacarpophalangeal joint is maintained in a
flexed position. B: Prior to pin advancement, the wire is positioned collinear with the long axis of the metacarpal
shaft.
Fluoroscopy is repeated to check the overall alignment of the pin and its insertion site. The fracture site is
visualized to check reduction. Once anatomic alignment has been confirmed, the wire is advanced across the
fracture, down the medullary canal, and into the proximal cortex. Ideally, proximal fixation is obtained with cortical
purchase in the metacarpal base or metaphysis (opposite cortex from initiation point) (Fig. 5-5). Crossing the
CMC joint to allow the pin to reside in the distal carpus is typically not problematic.
Maintenance of fracture reduction and pin placement is confirmed with intraoperative imaging. A second pin of
the same caliber is placed in the opposite collateral recess using the previously discussed technique. Often, the
two pins obtain a crossed configuration proximal to the fracture site. With the pins in place, the stability of the
fracture fixation and the rotational alignment are assessed. The pins are bent at 90 degrees and cut (Fig. 5-6). A
bulky dressing and protective splint are applied.
FIGURE 5-5 Ideally, the collateral recess pins occupy a crossed configuration within the medullary canal with
purchase in the proximal metacarpal metaphysis.
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FIGURE 5-6 Kirschner wires are bent and cut after fluoroscopic confirmation of the collateral recess pins.
FIGURE 5-7 The length and location of the typical incision for fifth metacarpal bouquet pinning is shown.
Bouquet Pinning
An alternative method of pin fixation may be considered when treating distal third metacarpal fractures involving
the border digits. In metacarpal neck fractures that are reducible but unstable, “bouquet pinning” or
intramedullary stabilization can be utilized.
The incision is distant from the distal metacarpal fracture site. It is made at the glabrous border over the tubercle
of insertion of the extensor carpi ulnaris (ECU) tendon (Fig. 5-7). The length of the incision may vary with patient
size, but 2.0 cm to 3.0 cm is standard. Care must be exercised to avoid damage to smaller arborizations of the
dorsal sensory branch of the ulnar nerve. Typically, the main sensory branch crosses the midaxis, an imaginary
line drawn between the ulnar styloid and the ECU tubercle, about halfway between these structures. Thus, it is
conceivable that handling of the nerve will be necessary, even through such a limited incision (see Fig. 5-2).
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Because a relatively volar starting point is desired, the ECU tendon should be reflected dorsally, but splitting the
insertion as it fans to a broader area is acceptable. There is a small area of prominence, a “shoulder,” at the
ulnar metacarpal base that presents a convexity relative to the juxtaarticular margin at the CMC joint and the
remainder of the metaphysis; it is at this area, or just proximal to it, that the intramedullary canal should be
entered (Fig. 5-8A, B). Use of fluoroscopy to
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locate the entry site is recommended to avoid potential pitfalls (Fig. 5-8C). If the cortical window is made too
proximal, intra-articular fracture into the CMC joint could result. More commonly, the entry is too distal, which
makes introduction of the pin arduous as it has difficulty by passing the narrow isthmus.
FIGURE 5-8 A: The entrance site is located just proximal to the convexity at the base of the small finger
metacarpal. B: A sagittal plane view of the fifth metacarpal shows the close proximity of the cortical window to
the juxta-articular margin. The length of the portal measures approximately 4 to 6 mm. C: With the use of
intraoperative image intensification, the starting point can be localized with a hypodermic needle.
Cortical perforation can be accomplished with hand tools or power drills. After initial opening of the canal, the
entry site is best enlarged with curettes. Because the direction of the tools entering the canal influences the tract
taken by the fixation pins, the introitus should be machined with the most acute angle possible (Fig. 5-9).
Although the integrity of the metacarpal base must be maintained, the portal of entry must be large enough to
accommodate the desired number of pins (usually three). The size of the hole is approximately 4 to 6 mm in
diameter. The portal is made ovoid to minimize the chance for fracture propagation due to this stress riser.
While the skin edges and ECU are retracted, access to the canal should be unrestricted, and attention is turned
to preparation of the pins for insertion. To minimize tourniquet time, the pins can be prepared ahead of time, with
some consideration of the individual patient's anatomy. Most commonly, a 0.045-inch smooth wire is the implant
of choice. Occasionally, a 0.062-inch wire may be required for extremely large hands. The 0.035-inch wire can
be used for gracile metacarpals or for secondary or supplemental pins after instrumenting the canal with a 0.045-
inch wire.
The next three steps are critical to successful bouquet pinning:
1. Cut the sharp tips off the pins. Leaving the sharp tip may create a second perforation in the cortex. The
additional cortical defect often captures the pin on subsequent passes, complicating the procedure.
2. Bend the pin throughout its length. The pin is contoured with a gentle bend along its entire body. The best
way to describe the bend is to liken it to a catenary or a telephone wire between two points. Minor adjustments
are made to conform to the individual canal morphology, but the typical prebend as described will suffice for
the majority of pins.
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3. Deflect the tip of the pin at its leading end. The creation of a bend allows the pin to “bounce off” the
endosteum of the canal and gives the pin direction. The secondary bend is performed in the same plane as
the primary arc, but is placed about 3 mm from the end of the pin to be introduced into the canal end that will
eventually reside distal to the fracture in the metacarpal head (Fig. 5-10).
FIGURE 5-9 A: The canal is entered with a drill or awl. The starting point and direction of cortical perforation are
both critical elements for eventual success. B: It is helpful to create a conduit in the metaphyseal bone of the
metacarpal base that influences the direction of the pin.
FIGURE 5-10 A: The pin adjacent to the hand is prebent for the specific reasons described in the text. B: A
secondary bend is fashioned in the same plane as the primary arc, placed 3 mm from the end of the leading
edge of the pin.
The pin is best controlled with two large needle holders that can be used to advance the implant and reorient it
inside the canal. This will allow for controlled progression of the pin and optimize its position in the metacarpal
head. The position of the terminal bend is inferred from the greater arc of the pin, directing the tangential contact
of the pin with the endosteum and determining that the “bouquet” can reliably be accomplished by paying
attention to the three-dimensional characteristics of the bent pin.
There are two useful techniques that can facilitate the procedure. First, using one needle holder to advance the
pin, while the second is grasping nearer the insertion site, serves to “stiffen” the implant and permit easier
passage (Fig. 5-11). Second, radial deviation of the hand (for fifth metacarpal fractures, or ulnar deviation for
second metacarpal fractures) makes pin introduction more facile.
The senior author has reluctantly used as few as two pins to stabilize a fifth metacarpal head fracture in a small
patient with a gracile canal. However, we advocate the use of at least three pins in most circumstances. The
maximum number we have used is six pins (a combination of 0.035-inch and 0.045-inch wires in a large male
patient).
Viewing the fracture under biplanar imaging intensification to ensure reduction is crucial. Before passing the
leading edge of the pin across the fracture site, a manual reduction maneuver must be performed (Fig. 5-12).
Perforation of the pin through the (dorsal) cortex of the shaft or through the fracture site must be guarded
against. If these difficulties occur, partial or complete removal of the pin from the canal and reorientation by
utilizing the two needle holders will usually rectify the problem. At times, two or more pins may act as a “track” for
subsequent pin insertions; typically, this is beneficial, yet this arrangement can also preclude placement of the
pin in the desired location.
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FIGURE 5-11 The passage of the pin within the metacarpal canal is facilitated by the surgeon positioning the
two needle holders as depicted in the illustration.
FIGURE 5-12 A reduction maneuver is performed before passing the wire across the fracture site.
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FIGURE 5-13 The wire ends naturally recess into the metacarpal canal and can be further secured by gentle
bone tamp use.
Once the fracture has been reduced and the pins placed, the ends are cut as close to the canal as possible (Fig.
5-13). The pins can be advanced slightly with a bone tamp, providing there is enough room at the distal aspect
of the metacarpal head. The proximal ends of the pins reside in the canal and are sometimes locked into position
by the proximal lip of the cortical perforation.
The soft tissues are closed over the cortical defect. The skin is closed with a nylon suture. A bulky dressing is
applied to the level of the proximal interphalangeal joint (PIP) that restricts MCP joint motion only slightly.
OPEN TREATMENT
Distal Third Metacarpal Fractures
Fractures of the distal third metacarpal are divided into the following categories:
Intracapsular fractures, with special emphasis on coronal splitting fractures of the metacarpal head
True neck fractures that involve the region from the juxta-articular margin to the metadiaphysis, including the
collateral recesses
Distal shaft fractures
Intracapsular Fractures
Intra-articular fractures often occur within the index ray. Several different fracture patterns exist for intracapsular
fractures of the metacarpal including two-part, comminuted, ligament avulsion and concomitant metacarpal neck
fractures.
In the case of head splitting fractures, there are three types of patterns: coronal, sagittal, and oblique. These
two-part fractures are often amenable to open reduction and screw fixation. The joint is approached by splitting
the extensor mechanism. A longitudinal skin incision is performed just ulnar to the metacarpal phalangeal joint.
The extensor tendon is split longitudinally to expose the dorsal capsule of the MCP joint (Fig. 5-14). Full-
thickness radial and ulnar capsular flaps are developed to expose the articular surface. Meticulous handling of
the articular fracture is critical to preserve vascularity and avoid iatrogenic injury. The fracture may be mobilized
and reduced with the use of a dental pick. After anatomic reduction is achieved, the fracture is stabilized with a
micro- or mini headless compression screw. If the size of fragment allows, an additional derotational K-wire can
be placed during screw fixation. The headless device is advanced until the proximal portion of the screw is just
deep to the articular surface (Fig. 5-15).
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FIGURE 5-14 After exposure of the extensor mechanism, the central tendon is split longitudinally over the MCP
joint. The extensor hood and sagittal bands are mobilized and the dorsal capsule incised.
FIGURE 5-15 A: The radiographs demonstrate displaced metacarpal head fracture involving the ling finger. B,C:
A dorsal approach to the metacarpal head was undertaken with subsequent reduction and internal fixation with a
microheadless screw. Postreduction radiographs demonstrate anatomic reduction with the headless screw
placed deep to the articular surface.
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FIGURE 5-15 (Continued)
Neck Fractures
Surgical stabilization options for the metacarpal neck include closed reduction and percutaneous pinning, open
reduction with pinning or internal fixation, and intramedullary pinning. When determining the type of fixation
device in fractures of the metacarpal neck, it is critical to assess the pathoanatomy of the fracture. Specifically,
fracture extension into the collateral recess may complicate the surgeon's ability to maintain anatomic reduction
with conventional pinning. Highly comminuted or significantly displaced fractures may not be amenable to closed
reduction and stabilization. Open reduction with minicondylar plate stabilization may be required in these injuries.
Associated soft-tissue injuries may also determine the type of fixation.
Distal Third/Middle Third Fractures

In distal third and middle third shaft fractures, the type of fixation is determined by the fracture configuration
(transverse, oblique, and spiral fractures). The condition of the soft-tissue envelope and level of comminution
may influence the method of stabilization.
Transverse Fractures
Transversely oriented fractures of the distal third metacarpal shaft that are reducible but unstable, intramedullary
fixation, or bouquet pinning may be utilized. In the case where a transversely oriented metacarpal shaft fracture
is proximal to the metadiaphyseal junction, collateral recess pinning may be indicated (see Fig. 5-6). If the
diaphyseal fracture is unreducible, open reduction and dorsal plate fixation is recommended. Most commonly, a
2.0 or 2.4 straight plate is utilized. Two screws are placed distal to the fracture in neutral. Proximal to the
fracture, the drill is placed eccentrically away from the fracture within the hole of the plate. Advancement of the
screw provides a compression force across the fracture site. Four or six screws are placed to stabilize the
fracture. Four to six cortices proximal and distal to the fracture site are desirable. In cases of transverse fractures
involving the metadiaphyseal junction, an L- or T-shaped plate may be required. The plate is placed in
compression as described in Figure 5-16.
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FIGURE 5-16 A reduced transverse metacarpal shaft fracture is diagrammed. A: Two drill holes are centered in
the plate holes distal to the fracture. The miniplate has a graduated bend of approximately 5 degrees centered at
the middle of the miniplate with no acute bend or buckling of the plate, especially not at the level of the holes in
the plate. B: Two neutral (centered in the plate holes and applying no force to the plate) miniscrews are inserted
distal to the fracture. A drill hole is placed eccentrically away from the fracture in the miniplate hole just proximal
to the fracture. C: A miniscrew is inserted into the eccentrically placed drill hole. D: The screw head engages the
plate hole as the miniscrew is tightened, causing the fracture to compress as the plate moves proximally. E: A
drill hole is centered in the remaining proximal plate hole. F: A neutral miniscrew is inserted, completing the
fixation. The sequence of miniscrew insertion is numbered. G,H: AP and lateral x-rays demonstrate a displaced
unstable fourth metacarpal shaft fracture with shortening and angulation in both the AP and lateral planes. There
was also rotational malalignment of the ring finger with digital flexion.
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FIGURE 5-16 (Continued) I: The fracture has been exposed. J,K: A curette and rongeur are used to remove clot
and granulation tissue at the fracture site. L: The fracture is reduced by manipulation and instrumentation using
bone reduction forceps. Rotational alignment is checked with the fingers flexed into a fist. M: A four-hole slightly
bent (5 degrees) straight miniplate is centered over the fracture. N: The distal fracture fragment is initially
secured with a neutral miniscrew inserted into the plate hole just distal to the fracture. An eccentric hole is drilled
through the miniplate hole just proximal to the fracture.
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FIGURE 5-16 (Continued) O: A second miniscrew is inserted into the eccentric drill hole. Engagement of the
screw head with the plate hole has compressed the fracture. P: Two neutral miniscrews are inserted into the
remaining plate holes to complete the construct. Q,R: Postoperative anteroposterior and lateral x-rays
demonstrate stable anatomic fracture fixation. (A through F from Heim U, Pfeiffer KM, eds. Internal Fixation of
Small Fractures, 3rd ed. New York: Springer Verlag, 1988:54-55. Figs. 31 and 32.)
Long Oblique Diaphyseal Fractures

Oblique or spiral fractures while sometimes reducible are often unstable owing to the configuration particularly in
the border digits. The length of the spiral fracture will often determine the type of implant utilized. In cases where
the length of the fracture is greater than twice the diameter of the metacarpal shaft, interfragmentary screw
fixation can be utilized. Two or more 2.0 or 2.4 lag screws are often satisfactory to stabilize this type of fracture.
Once the fracture has been reduced and provisionally stabilized, inspection of the fracture length will help
determine the location and potential number of screws for stabilization. In general, two screws are utilized in
fracture lengths that are twice the diameter. When fracture length exceeds three times the diameter, then fixation
may be achieved with three screws. Interfragmentary screws may be placed in compression or neutralization. By
definition, compression screws are placed perpendicular to the fracture in lag fashion and provide the greatest
compressive force. A neutralization screw is positioned perpendicular to the long axis of the diaphysis and
provides resistance to shear forces. In cases of long spiral fractures, it is usually possible to place a lag screw
that is both perpendicular to the fracture and long axis of the bone. If it is not possible to place a screw in this
orientation, attempts are made to position both a screw in compression and neutralization mode to improve
stability of fixation. Countersinking is performed when possible to improve load characteristics. The technique of
lag screw fixation is detailed in Figure 5-17.
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FIGURE 5-17 A,B: A displaced unstable long spiral fracture of the third metacarpal shaft. C: The fracture is
reduced and secured with a pointed reduction forceps. A gliding hole is drilled in the near cortex with a 2.7-mm
drill. A drill guide is used to protect adjacent soft tissues and to prevent skating of the drill on the bone. D: The
opposite end of a double-ended drill guide corresponds to the 2.7-mm diameter of the gliding hole. The drill
guide is inserted in the gliding hole in the near cortex, and a 2.0-mm core hole is drilled concentrically through
the opposite cortex. E: The countersink is rotated to fashion an area in the proximal half of the dorsal cortex to
correspond to the screw head. F: A depth gauge determines the length of the screw hole.
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FIGURE 5-17 (Continued) G: A 2.7-mm tap is used to thread the core hole of the distal cortex. A tap sleeve is
used to protect adjacent soft tissues. This step is omitted when self-tapping screws are inserted. H: A miniscrew
is inserted. As it glides through the proximal hole, the head of the miniscrew engages the proximal cortex,
creating compression at the fracture site as the screw threads purchase the distal cortex (lag screw effect). Note
that a compression miniscrew is inserted perpendicular to the fracture. I: A second miniscrew is inserted using a
similar technique to the first but in a plane perpendicular to the long axis of the bone, satisfying the need for
maximum neutralization of shearing forces. J,K: AP and lateral x-rays demonstrate an anatomic reduction of the
fracture secured with two minilag screws.
Sagittal Short Oblique Diaphyseal Fracture

In cases of spiral fractures whose length is less than twice the diameter of the bone, interfragmentary screw
fixation alone will not provide sufficient fixation. Stability of short oblique metacarpal fractures is best achieved
with a single interfragmentary screw and a neutralizing dorsal plate. Following anatomic reduction and
provisional stabilization, a lag screw is placed in compression. The screw is positioned away from the dorsal
cortex to allow plate stabilization. A five- or seven-hole plate (if possible) is then contoured to the dorsal cortex.
The center most hole is positioned over the lag screw. This hole is left empty. Attempts are made to obtain at
least two screws with bicortical purchase proximal and distal to the fracture site. Depending on the location of the
fracture within the diaphysis, a T-plate may be indicated to obtain satisfactory purchase.
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Proximal Third Fractures
Proximal fractures of the metacarpal can be divided into two categories: shaft and intra-articular. Once again, in
cases of proximal shaft fractures, they are divided into short oblique, spiral, and transverse. The short oblique or
transversely oriented fracture may be treated with closed reduction and collateral recess pinning versus open
reduction internal fixation when operative indications are present. Metacarpal shaft fractures treated with closed
reduction percutaneous pinning often require passage of the pin across the CMC joint (Fig. 5-18). In cases of
oblique/spiral or intra-articular fractures, open reduction and internal
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fixation may be performed with an L- or T-plate. This type of plate configuration allows for adequate fixation
proximal to the fracture site. Plates with locking options are beneficial when attempting to improve the quality of
fixation within the proximal metaphyseal bone in periarticular fractures.
FIGURE 5-18 A: After closed reduction of the small finger metacarpal base fracture, the fragment was stabilized
with a 0.045 smooth wire placed from the radial collateral recess. B: A second pin was placed from the ulnar
collateral recess across the CMC joint for added stability. C,D: Stabilization of the long finger metacarpal shaft
fracture was achieved with collateral recess pinning. Both the radial and ulnar recess wires were advanced
across the CMC joint to secure fixation of the long finger metacarpal diaphyseal fracture.
Metacarpal fixation with collateral recess pinning requires approximately 4 weeks of immobilization in a safe-
position splint; in most patients, the PIP joint can be free. Because pin stability and pin tract infections are
concerns, appropriate immobilization is required when the pins are indwelling. This is accomplished with rigid
immobilization for 3 to 4 weeks followed by interval splinting. Careful motion of adjacent digits and even other
digital segments of the operated ray can be initiated. Active and active-assisted motion of the DIP, PIP, and MCP
joints commences following pin removal at approximately 1 month post-op. The patient is maintained in an
orthosis for an additional 2 weeks. With clinical and radiographic signs of healing, the splint is gradually weaned.
Closed Pinning
Following bouquet pinning, the patient is maintained in the soft postsurgical dressing for 1 to 2 weeks. Most
patients should expect to have enough pain control to initiate mobilization within the bulky dressing during the
first week. Active and active-assisted motion commences within the first 7 to 10 days.
Sutures are removed at 10 to 14 days, at which time radiographs are obtained. A removable, short arm, safe-
position orthosis is furnished to immobilize the hand during the intervals between exercise sessions. Passive
motion is initiated after clinical and radiographic healing is achieved. Strengthening is started after satisfactory
motion has been achieved along with radiographic healing. Interval splinting with intermittent range of motion is
permitted.
Open Reduction
In most cases, lag screw fixation or plate stabilization provides a rigid construct permitting early motion and return
to activities. Three to five days following open reduction and internal fixation, patients begin active range of
motion with protective splinting. The surgical hand is placed positioned into a forearm-based splint that includes
the MCP joint. Aggressive efforts are made to restore full flexion of the MCP joint. Light passive motion of the
interphalangeal joints is initiated within 2 to 3 weeks after the procedure. Active motion takes place at 3 to 4
weeks post-op. As healing permits, light strengthening exercises are started between 4 and 6 weeks.
RESULTS
Because the patient can pursue a program of interphalangeal motion and no direct manipulation of these
levels is undertaken, the PIP and DIP joints usually recover motion rapidly. A program of blocked flexion and
intrinsic stretching can assist in accelerating the functional return.
The MCP joints are initially limited in motion. The most frequent presentation is that of extension lag, which
sometimes exceeds 30 degrees. This result is likely due to the influence of the fracture callus and the
extensor penetration by the pins. Because the collateral ligaments are held at their greatest length during
pin insertion, the lag is probably not related to capsuloligamentous contracture. The extensor has relatively
little excursion through the composite motion arc (compared to the flexors), which may help to explain this
phenomenon.
Flexion usually returns rapidly and heralds greater functional capability, such as grasping, which is key for
strengthening tasks. As long as the fracture is believed to be clinically united, the pursuit of MCP motion
can be aggressive. In addition to night splinting in extension and any active motion, intrinsic stretching and
even dynamic splinting is reasonable.
Eventually, buddy taping to an adjacent normal digit can assist in promoting a greater arc of motion. Return
to contact activities is safe if comfort and reasonable function has been demonstrated. This is typically
between the 6th and 8th postoperative weeks or the 3rd to 4th week after the pins have been discontinued.
Our experience with collateral recess pinning now exceeds 100 patients. To date, we have not experienced
any major complications, and healing of the fractures has been seen in all patients, including multiple-
fracture cases.
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Pin tract infections have occurred in less than 5% of patients and have been treated with pin removal, local
wound care, and oral antibiotics. We have not seen any cases of septic arthritis. Although it is difficult to
categorize patients on whom this technique has been employed, we can state that no significant motion
limitation, strength compromise, or repeat surgery has been associated with the subgroup of patients
treated for closed fractures.
Because we employ this technique for even more complex injuries, including open fractures and combined
injuries (skin, bone, tendon, nerve, and vessel), revision, or salvage, surgery has been employed in some
cases to maximize results. We have not found any untoward sequelae related to this fixation method.
Bouquet Pinning
The ability of bouquet pinning to reduce fractures, stabilize them rigidly, and permit early motion is
unparalleled. The opportunity to operate away from the joints of the osteoarticular column of the hand,
where there is such a premium on flexibility, is tremendously attractive.
We have now employed the bouquet-pinning technique in over 100 patients. Over 90 of those cases have
involved the fifth metacarpal. To date, there have been no significant complications. We have noted no
iatrogenic nerve injuries, hardware migrations, loss of reduction, infections, or need for repeat surgery.
Even in cases of complex fracture patterns of open injuries (six cases), this technique has proven
complication-free.
One of the most impressive observations about this tool is the abundant fracture healing response that
accompanies pin placement. Often, early callus is seen on radiographs at initial postoperative visits
between 10 and 14 days after surgery. Most patients already have recovered between 50% and 75% of
their composite motion at the MCP, PIP, and DIP joints by that first visit because the bulky dressing has not
restricted their motion.
The only clinical issue we have encountered is a lingering (6- to 8-week) soreness at the incision site. This
appears to be related to the difficulty with which the initial access the canal was gained. This predictable
sequela responds to aggressive scar massage and initial pad protection if early contact is required by the
patient's vocation or avocation. We have not encountered pin migration or need for pin removal because we
place the proximal pin ends within the metacarpal shell.
Open Treatment
The majority of patients undergoing open reduction internal fixation for simple metacarpal fractures do well.
Union rates for these injuries are greater than 95%. Greater than 75% of patients achieve 220 degrees of
total active motion. Outcomes following metacarpal fixation are influenced by the degree of comminution
and severity of soft-tissue injury. Reoperation rates approach 15% in open metacarpal injuries. Nonunion
and infection rates are increased in open injuries compared to metacarpal fixation in hand injuries with an
intact soft-tissue envelope.
COMPLICATIONS
Closed Pinning
Bouquet intramedullary pinning of metacarpal fractures yields few postoperative complications. Reported
complications are dorsal ulnar sensory nerve embarrassment, reflex sympathetic dystrophy, infection, and
discomfort at the base of the operated metacarpal, yet these untoward occurrences are infrequent.
Injury to the dorsal ulnar sensory nerve can be avoided with careful attention to surgical dissection and
awareness of local anatomy. The few reported cases of reflex sympathetic dystrophy have been associated
with crush injuries and multiple metacarpal fractures. Some complications can occur as a result of technical
error. Penetration of the wire through the MCP joint, extensor tendon rupture secondary to proximal
protrusion of the wire, and secondary displacement of the fracture after early wire removal have been
reported. In our practice, hardware removal is not advocated.
Although rare for closed pinning of metacarpal fractures, nonunion has been reported.
Open Treatment
Despite aggressive measures to mobilize the operated digit early, stiffness is still one of the most common
sequelae. Capsular adhesions and scarring of the extensor mechanism following operative plate fixation in
a simple metacarpal fracture occur in approximately 15% to 20% of cases.
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This percentage increases in cases of open or crush injuries. Reoperation may require MCP joint
capsulectomy and extensor tendon tenolysis. Postoperative infections average 0.5% in closed injuries and
approach 11% with open fractures. Rarely, bone grafting is required for delayed or nonunion in closed
metacarpal injuries.
RECOMMENDED READING
Blazar PE, Leven D: Intramedullary nail fixation for metacarpal fractures. Hand Clin 26(3): 321-325, 2010.
Botte MJ, Davis JL, Rose BA, et al.: Complications of smooth pin fixation of fractures and dislocations in the
hand and wrist. Clin Orthop Relat Res 276: 194-201, 1992.
Duncan RW, Freeland AE, Jabaley ME, et al.: Open hand fractures: an analysis of the recovery of active
motion and of complications. J Hand Surg Am 18(3): 387-394, 1993.
Foucher G: Bouquet osteosynthesis in metacarpal neck fractures. A series of 66 patients. J Hand Surg 20(3
Pt 2): S86-S90, 1995.
Freeland AE, Jabeley ME: Open reduction internal fixation: metacarpal fractures. In: Strickland JW, ed.
Master techniques in orthopaedic surgery: The hand. Philadelphia, PA: Lippincott-Raven, 1988: 3-33.
Fusetti C, Meyer H, Borisch N, et al.: Complications of plate fixation in metacarpal fractures. J Trauma 52(3):
535-539, 2002.
Henry MH: Fractures of the proximal phalanx and metacarpals in the hand: preferred methods of stabilization.
J Am Acad Orthop Surg 16(10): 586-595, 2008.
Kozin SH, Thoder JJ, Lieberman G: Operative treatment of metacarpal and phalangeal shaft fractures. J
Acad Orthop Surg 8: 111-121, 2000.
McLain RF, Steyers C, Stoddard M: Infections in open fractures of the hand. J Hand Surg Am 16(1): 108-
112, 1991.
Ozer K, Gillani S, Williams A, et al.: Comparison of intramedullary nailing versus plate-screw fixation of extra-
articular metacarpal fractures. J Hand Surg Am 33(10): 1724-1731, 2008.
Page SM, Stern PJ: Complications and range of motion following plate fixation of metacarpal and phalangeal
fractures. J Hand Surg Am 23(5): 827-832, 1998.
Rettig LA, Graham TJ: Closed pinning and bouquet pinning of fractures of the metacarpals. In: Strickland JW,
Graham TJ, eds. Master techniques in orthopaedic surgery: The hand. 2nd ed. Philadelphia, PA: Lippincott
Williams & Wilkins, 2005: 27-46.
Ring D: Malunion and nonunion of the metacarpals and phalanges. Instr Course Lect 55: 121-128, 2006.
Tan JS, Foo AT, Chew WC, et al.: Articularly placed interfragmentary screw fixation of difficult condylar
fractures of the hand. J Hand Surg Am 36(4): 604-609, 2011.
Yaffe MA, Saucedo JM, Kalainov DM. Non-locked and locked plating technology for hand fractures. J Hand
Surg Am 36(12): 2052-2055, 2011.
Chapter 6
Operative Fixation of Juxta-Articular, Intracapsular, and
Diaphyseal Fractures of the Phalanges and Interphalangeal Joints
David E. Ruchelsman
Matthew I. Leibman
Mark R. Belsky
Thomas J. Graham
The phalanges are short tubular bones, but tend to exhibit similar fracture patterns to the long tubular bones of
the skeleton. Phalangeal fractures are subject to displacement, angulation, and malrotation due to forces
exhibited by the traversing flexor and extensor tendons and collateral ligaments at juxta-articular locations. The
metaphyseal and articular fractures are subject to compressive forces and joint impaction, and diastasis can be
challenging to reconstruct. The etiology of digital stiffness following operative fixation of unstable phalangeal
diaphyseal, juxta-articular, and intra-articular fractures may be multifactorial. Malreduction with resultant soft-
tissue imbalances, extensor/flexor tendon adhesions, and capsular contractures may be minimized with
meticulous operative technique and initiation of early functional rehabilitation.
Conceptually, we divide phalangeal fractures into articular and nonarticular injuries involving the proximal,
middle, and distal phalanges. Extra-articular fractures include fractures of the neck, shaft, or base. Articular
fractures include unicondylar fractures; comminuted intra-articular fractures (i.e., bicondylar fractures); dorsal,
volar, or lateral base fractures; pilon fractures and fracture-dislocations; and diaphyseal fractures with articular
extension.
EXTRA-ARTICULAR PHALANGEAL FRACTURES

Diaphyseal Phalangeal Fractures
Phalangeal fractures may be transverse, oblique, spiral, or comminuted/multifragmentary. The latter are usually
associated with significant soft-tissue injury even if the overlying skin envelope is intact. Spiral and oblique
fractures are more common in the proximal phalanx diaphysis, and transverse fractures tend to be more common
in the middle phalanx and proximal third of the proximal phalanx.
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Transverse proximal phalangeal fractures tend to collapse into an apex volar angulation, with the proximal
metaphysis flexed by the interosseous insertion. The remainder of the phalanx then collapses into extension due
to the longitudinal pull of the extrinsic extensor. Angulation of middle phalangeal fractures is generally apex
dorsal as the sublimis insertion along the distal fragment draws the distal fragment into flexion.
Management of phalangeal fractures depends on the following factors: displacement, fracture geometry, soft-
tissue injury, and patient characteristics and requirements. Treatment should be tailored to the individual taking
into consideration fracture characteristics.
Oblique and spiral fractures are prone to shortening and malrotation when treated nonoperatively. Periarticular
oblique fractures may involve the collateral recess or subcondylar fossa and effect function. Comminuted
fractures are prone to shortening, soft-tissue adhesions, delayed healing, and stiffness.
Greater than 10 degrees of malangulation in the coronal or sagittal plane
Malrotation
Shortening
Open fractures
Combined injuries
Regional versus local anesthesia
Mini-C arm
Kirschner wires (0.045 inch, 0.035 inch)
Modular plate/screws (1.5 mm, 1.3 mm, 1.1 mm)
Techniques
Closed Reduction and Percutaneous Pinning Percutaneous K-wire fixation is the most common method of
operative stabilization of unstable proximal and middle phalangeal shaft fractures once satisfactory reduction has
been achieved. Care is taken to try and avoid violation of the extensor hood, central extensor tendon, and
neurovascular bundles. Early range of motion following percutaneous K-wire fixation is often limited as skin
motion at the pin sites may lead to superficial and/or deep pin site infections.
K-wire placement depends on the fracture pattern, configuration, and bone quality. Proximal metaphyseal
fractures at the base of the proximal phalanx usually demonstrate dorsal cortical comminution with apex volar
angulation. Multiple adjacent fingers can fracture in this fashion in the elderly osteoporotic individual after a fall.
Imaging of the phalangeal base is difficult especially after an acute injury. While these fractures are reducible
with digital flexion, they are inherently unstable. These fractures may also extend proximally and involve the
articular surface.
Antegrade crossed K-wires beginning at the periphery of the articular margin are often used to stabilize these
fractures (Figs. 6-1 and 6-2). The metacarpophalangeal (MCP) joint is flexed maximally and the distal fracture
fragment of the proximal phalanx reduced to the metaphyseal segment.
Alternatively, these fractures can be stabilized with a longitudinal wire passed antegrade through the metacarpal
head into the medullary canal of the proximal phalanx (1). Additional pins may be inserted to provide rotational
stability especially in more distal fractures. Each technique has inherent advantages and disadvantages.
Patients are counseled regarding the potential for extensor and/or flexor tendon adhesions at the level of the
metaphyseal fracture corresponding to the A2 pulley. At times, tenolysis of the flexor system and/or
MCP/proximal interphalangeal joint (PIP) contracture releases are needed following osseous union.
Oblique and spiral fractures may be stabilized with two or more K-wires passed percutaneously perpendicular to
the fracture plane. If one elects percutaneous fixation of these rotationally unstable fractures, it is imperative to
use fluoroscopy to ensure that the wires truly engage in a bicortical fashion and in the plane perpendicular to the
plane of the fracture (Fig. 6-3). Transverse or short oblique wires can be fixed with crossed K-wires. As crossing
K-wires tend to distract the fracture, manual compression must be applied to the digit at the time of insertion of
the second wire. The fracture is usually immobilized for approximately 3 weeks, and the wires are then removed
followed by protected motion with buddy taping.
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FIGURE 6-1 A: Proximal phalangeal metaphyseal fracture with articular extension. Apex volar angulation is
seen. B: Closed reduction and percutaneous crossed K-wire fixation is achieved. C: Osseous union with
anatomic articular and metadiaphyseal alignment.
FIGURE 6-2 A: Proximal phalangeal metadiaphyseal fracture with rotational and sagittal plane deformity. B:
Closed reduction and percutaneous crossed K-wire fixation is achieved. C: Osseous union with anatomic
articular and metadiaphyseal alignment. Full motion was achieved at latest follow-up.
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FIGURE 6-3 A: Rotationally unstable middle phalanx oblique diaphyseal fracture. B: Closed reduction and
percutaneous parallel K-wires perpendicular to the plane of the fracture. Postoperatively, a DIP joint tip protector
splint is utilized while early PIP joint motion is initiated.
Pearls and Pitfalls

Avoidance of an intra-articular starting point with antegrade crossed K-wire fixation of proximal phalangeal
metaphyseal/diaphyseal fractures.
Use of intrinsic plus casts/splints to minimize MCP joint stiffness and contracture.
Avoidance of K-wires placed through the collateral recess of the interphalangeal joints to minimize collateral
ligament contracture.
Newer fixation systems with self-tapping mini-screws allow for percutaneous screw fixation through small
incisions after reduction. Percutaneous screw fixation achieves interfragmentary compression and may allow
for earlier motion.
Use of local anesthetic and active motion in the early postoperative period (i.e., 4 to 6 weeks) may facilitate
“closed tenolysis” and yield increases active composite flexion.
Postoperative Management Initiation of mobilization is based on clinical tenderness as early clinical union
precedes radiographic union. Following clinical union (typically 4 to 6 weeks postoperatively), a digital block may
be performed in the office if there is early postoperative digital stiffness followed by active digital motion to
attempt “closed tenolysis” of early adhesions and facilitate recovery of digital motion. Sagittal plane malunion
may result in clinical pseudo-claw deformity and extensor imbalance with resultant extensor lag.
Open Reduction and Internal Fixation Open reduction is indicated for irreducible phalangeal fractures, open
fractures, and combined injuries. Stable internal fixation facilitates early postoperative functional rehabilitation.
A dorsal curvilinear or lateral/midaxial incision is most frequently utilized for proximal phalangeal exposure.
Several deep surgical intervals exist. For diaphyseal fractures of the proximal phalanx, the interval between the
central extensor tendon and lateral band may be incised, or the extensor may be mobilized together with the
ipsilateral conjoined lateral band (Fig. 6-4). For metadiaphyseal fractures, a unilateral intrinsic resection of the
lateral band and oblique fibers of the
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MCP joint facilitates mobilization and reflection of the central extensor tendon in a supraperiosteal fashion (2)
(Fig. 6-5). The periosteum is incised along the obliquity of the fracture to allow for anatomic reduction and
internal fixation. This exposure is especially useful for lateral plate fixation of unstable proximal phalanx fractures.
Lateral plate application minimizes interference with extensor tendon excursion. Furthermore, biomechanical
analyses (3,4) have suggested that mid-lateral plate positioning may have superior biomechanical properties.
Alternatively, the extensor may be split in its midline for wide exposure of the fracture.
FIGURE 6-4 A: For diaphyseal fractures of the proximal phalanx, a dorsal curvilinear incision is used followed by
mobilization of the central extensor in a supraperiosteal fashion together with the ipsilateral conjoined lateral
band (star). B: Following mobilization of the extensor, the fracture is exposed and anatomically reduced along
cortical keys, followed by interfragmentary screws. C: Anatomic reduction and osseous union are achieved. A
small residual extensor lag at the PIP joint is expected.
Fractures of the distal third of the proximal phalanx can be exposed in a limited fashion for screw placement
without incising the extensor mechanism. The lateral band can be retracted dorsally following division of the
transverse retinacular ligament as is performed for fixation of unicondylar fractures (as outlined below).
Independent of deep exposure selected, the entire length of the fracture must be exposed, especially with spiral
fractures, prior to reduction. The apices must be visualized to confirm anatomic reduction and restoration of
length and rotation. Once the fracture is provisionally reduced with bone reduction forceps or K-wires, tenodesis
maneuver is performed to confirm restoration of the digital cascade. The fracture-specific fixation construct is
then selected.
Interfragmentary screws enhance stability compared to K-wires and wire loop fixation constructs. Screws alone
are best indicated for the stabilization of oblique and spiral fractures when the length of the fracture is more than
twice the diameter of the bone to allow placement
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of at least two screws (Figs. 6-6 and 6-7). Obtaining bicortical fixation is more imperative than is true lag
compression (5). When planning screw placement, care should be taken to stay a minimum of 2 screw diameters
away from the fracture margin to prevent cortical failure. Generally, 1.3-mm and 1.5-mm screws are used
depending on fragment size and comminution (Fig. 6-8).
FIGURE 6-5 A: Unstable and displaced ring finger proximal phalangeal metaphyseal fracture. Following
elevation of a full-thickness subcutaneous flap from the peritenon of the central extensor tendon, the conjoined
lateral band on the side of plate application is excised to facilitate fracture site exposure and reduction. B: Ulnar
(lateral) plate application following excision of the ulnar conjoined lateral band and fracture reduction. A
periarticular locking plate is selected based on the metaphyseal location of the primary fracture line. C: Final
radiographs demonstrate osseous union.
Plate fixation is indicated when K-wire or lag screw fixation is inadequate as in fractures with comminution,
articular fractures with extension into the shaft, and for reconstruction of nonunions and malunions. Additionally,
there are some fractures such as transverse fractures of the midshaft that are amenable to compression plating.
Plate stabilization is used in multifragmentary and comminuted phalangeal fractures. Complications of plate
fixation are related to their use in more complex cases and open fractures
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rather than the technique itself (6). Plates can be placed dorsally (Fig. 6-9) or laterally (Fig. 6-10) based on
fracture pattern and direction of displacement. While extensor irritation is less likely with lateral plate placement,
the latter is also more technically demanding due to the limited area of bone surface available. Generally a
minimum of four cortices should be fixed on either side of the fracture.
FIGURE 6-6 A: Long oblique proximal phalangeal fracture with shortening and disruption of the subcondylar
fossa. B: ORIF with two interfragmentary screws. C: Final clinical outcome demonstrate full composite digital
flexion and extension.
Several recent technical advances in plate and screw design have facilitated the application of plates to the
phalanges and may reduce complications. New plates are lower profile with varying shapes, thicknesses, and
recessed screw heads (Fig. 6-11). A particularly important advance is locking screw technology that allows the
screw to thread into the plate hole for added stability. Locking plates are particularly useful for osteopenic bone,
for comminuted fractures, and for periarticular fractures where the locking screws buttress the articular surface
(7).
External fixators are used for highly comminuted diaphyseal fractures precluding stable internal fixation,
combined injuries with bone and soft-tissue loss, and management of infected nonunions necessitating staged
reconstruction. External fixation avoids additional soft-tissue dissection and fragment devascularization. Various
unilateral fixators are available and multidirectional clamps allow fine tuning of fracture reduction following pin
placement.
Reduction of displaced/malangulated distal phalangeal diaphyseal and tuft fractures is considered in the setting
of significant sagittal plane deformity in order to repair the lacerated overlying nail matrix. The nail plate is
removed and the nail matrix is repaired followed reduction and K-wire fixation of the distal phalanx fracture.
Transarticular fixation is often performed to avoid early loosening of the K-wire(s).
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FIGURE 6-7 A: Rotationally unstable proximal phalangeal diaphyseal fracture. B,C: Extensor tendon
mobilization is facilitated with release of the ipsilateral lateral band proximally and the transverse retinacular
ligament distally, which facilitates exposure of the apices of the long oblique fracture. D: ORIF with
interfragmentary screws yields union and full functional arc of motion.
FIGURE 6-8 A: Multifragmentary ring finger proximal phalangeal fracture. B: Appropriately sized
interfragmentary screws were used to secure fixation of this multiplanar fracture.
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FIGURE 6-9 A: Ring finger proximal phalangeal fracture secondary to crush injury. B: Given the location of the
wound and the underlying combined extensor tendon injury, dorsal plating was performed. Ultimately, extensor
tenolysis, hardware removal, and PIP joint capsulectomy were required.
FIGURE 6-10 A: Malangulated comminuted index finger proximal phalangeal fracture. B: Following excision of
the radial conjoined lateral band, fracture reduction and stabilization was performed using a hybrid fixation
construct. A single interfragmentary screw secured an intercalary butterfly fragment, followed by lateral
application of a 1.5-mm periarticular locking plate based on the comminuted metaphyseal nature of this fracture.
FIGURE 6-11 A: Multifragmentary middle phalangeal periarticular fracture. B: Following fracture exposure on
each side of the terminal extensor tendon, dual column plating was performed using low profile anatomically
precontoured variable angle locking plates.
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Pearls and Pitfalls
Unilateral intrinsic resection of the lateral band and oblique fibers of the MCP joint allows for lateral plating of
proximal phalangeal fractures and minimizes postoperative extensor tendon adhesions.
Division of the ipsilateral transverse retinacular ligament facilitates lateral band mobilization for distal
diaphyseal fractures of the proximal phalanx and unicondylar fractures.
Repair of the periosteum over implants may minimize postoperative adhesions.
Interfragmentary screws are used when the length of the fracture is more than twice the diameter of the bone
to allow placement of at least two screws.
Visualize occult nondisplaced fracture lines that may preclude screw fixation.
Use of locking plate designs for comminuted and periarticular fractures.
Postoperative Management
Hand-based intrinsic plus splints are utilized.
Early functional rehabilitation following stable internal fixation is initiated within the first postoperative week.
Extensor adhesions are minimized by encouraging early active motion, functional splinting, and edema control.
Reverse blocking splints and exercises are utilized to minimize extensor lag at the PIP joint.
LMB splinting is used to address PIP flexion contractures.
Static and dynamic splints may be needed to address adhesions and joint contractures following clinical union.
Phalangeal Neck Fractures

Isolated subcondylar fractures of the neck of the phalanx are almost exclusively seen in children with the majority
occurring in toddlers. The mechanism of injury is usually from crush injury. Al-Qattan (8) classified pediatric
phalangeal neck fractures into nondisplaced, minimally displaced with partial contact of the bony fragments, and
completely displaced. The distal condylar segment can be displaced dorsally or volarly, and there may also axial
plane deformity (i.e., malrotation).
Indications/Contraindications Closed reduction and percutaneous wire fixation is recommended for all
displaced fracture of the phalangeal neck. Nondisplaced neck fractures are followed with serial radiographs to
confirm maintenance of reduction.
General anesthesia versus local anesthesia with sedation
Mini-C arm
Kirschner wires (0.045 inch, 0.035 inch, 0.028 inch)
Technique Following closed reduction, the fracture is often stabilized with oblique K-wires (Fig. 6-12) placed in a
retrograde fashion. At times for middle phalangeal neck fractures, a
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transarticular longitudinal K-wire may be used (Fig. 6-13). Limited open incisions may be necessary to facilitate
anatomic reduction prior to percutaneous pinning. Because of the narrow area of contact and lack of any soft-
tissue attachment to the distal fragment, these fractures are inherently unstable and displaced fractures cannot
always be reduced with closed techniques alone (Fig. 6-14).
FIGURE 6-12 A: Widely displaced and angulated phalangeal neck fracture. B: Closed reduction and
percutaneous pinning with crossed K-wire technique. C: Well-healed phalangeal neck fracture at 6 weeks.
FIGURE 6-13 Transarticular longitudinal K-wire fixation of displaced middle phalangeal neck fracture.
FIGURE 6-14 A: Skeletally immature patient with severe crush injury and complex combined injury. The skeletal
injury included an open distal phalanx transphyseal separation with an open comminuted displaced middle
phalangeal neck fracture. The phalangeal neck fracture was extremely unstable secondary to comminution and
severe soft-tissue injury. B: Clinical photos demonstrate a volar-radial softtissue degloving injury off of the flexor
sheath and the dorsal-ulnar extension of the soft-tissue injury. The digital arteries were lacerated requiring
revascularization, and the digital nerves contused. C: Reduction was obtained using the remaining cortical keys
along the dorsal ulnar neck (forceps). Bone grafting of the radial metaphyseal void was performed. The avulsed
terminal extensor was repaired.
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Pearls and Pitfalls
Non/minimally displaced phalangeal neck fractures are easily overlooked in the emergency department when
suboptimal orthogonal radiographs are obtained. A true lateral radiograph is required to appreciate more
subtle phalangeal neck fractures. In this view, displacement of the capital fragment or condylar malrotation is
best visualized.
Intraoperatively, care is taken to ensure that obliquely placed K-wires cross in the coronal and sagittal planes
proximal to the primary fracture line to maximize rotational stability.
A true lateral view is required to assess reduction of the subcondylar fossa.
Waters and colleagues (9) have proposed a treatment algorithm for skeletally immature phalangeal neck
fractures that present in a delayed fashion. Subacute fractures with residual tenderness at the fracture site
may be amendable to percutaneous osteoclasis, reduction and fixation. Open treatment is associated with
increased risk of osteonecrosis. Neck fractures with delayed presentation, minimal residual fracture site
tenderness, and satisfactory PIP motion are potentially better managed with observation and delayed
subcondylar recession if a block to flexion ensues (Fig. 6-15).
FIGURE 6-15 A: Skeletally immature patient with a proximal phalangeal neck nascent malunion. Delayed
presentation at 1 month postinjury. Sagittal plane displacement and abundant callus are noted at presentation.
Expectant management was selected because there was minimal fracture site tenderness at presentation, no
malrotation, and satisfactory early active (60 degrees) and passive (90 degrees) flexion. B: Remodeling noted at
the phalangeal neck at 1 year following initial fracture. C: Clinical exam demonstrated full motion at latest follow-
up.
In children, a cast is used until K-wire removal, typically between 3 and 4 weeks postoperatively. In adults, a
PIP or distal interphalangeal joint (DIP) joint splint can be used.
Complications
Sagittal plane malunion may result in loss of motion due to an altered arc of motion. Dorsal displacement
leads to an osseous flexion block at the subcondylar fossa.
Displacement in the coronal plane leads to angular deformity of the digit. As the injury is distant to the
growth plate, it is believed that remodeling potential is limited. There is recent clinical
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evidence that remodeling in the sagittal plane may occur even in older patient who remains skeletally
immature (10,11,12). Remodeling in the coronal and axial planes is less predictable.
Pin site infection
Joint stiffness
Chondrolysis and osteonecrosis of the capital segment
ARTICULAR PHALANGEAL FRACTURES

Condylar Fractures
Indications/Contraindications Condylar fractures affect the younger population and are usually sport-related
(13). Fracture orientations are determined by force vectors and the position of the digit at the time of impact.
Weiss and Hastings (13) classified these injuries:
Type 1: Unicondylar fracture with transverse metaphyseal fracture: These injuries are usually displaced and
malrotated and require open reduction and internal fixation (ORIF). If the fracture is nondisplaced,
immobilization with close serial radiographic follow-up is recommended given the potential for interval
displacement. Some hand surgeons recommend early percutaneous pin stabilization given the propensity of
these fractures to displace.
Type 2: Unicondylar fracture with an oblique metaphyseal fracture of varying length. This pattern is by far the
most common accounting for one-half to two-thirds of these fractures. Due to the obliquity of the metaphyseal
fracture, these fractures are highly unstable—even initially undisplaced fractures may settle during the healing
period and lead to an angular deformity of the digit.
Type 3: Bicondylar fracture with varying obliquity of the metaphyseal fracture.
Type 4: Coronal plane condylar fracture (dorsal or volar). Coronal fractures are usually unstable
osteochondral fragments. If the fragment is displaced, there is associated joint subluxation with proximal
displacement of the middle phalanx. CT scan is helpful preoperatively in planning surgical approach and
fixation.
Type 5: Triplane fractures of the head of the proximal phalanx have been described by Chin and Jupiter (14).
These are highly unstable articular injuries necessitating ORIF. Autogenous cancellous bone grafting may be
needed to support the articular fragments. When the articular surface is not reconstructable, implant
arthroplasty is considered.
Physical examination usually reveals rotational deformity during composite flexion or tenodesis. Scrutiny of
radiographs of the injured digit is essential to assess joint alignment, displacement, and condylar malrotation
in the sagittal plane.
In select cases, CT scanning may be necessary to assess the fracture planes and fragment size more
accurately.
General versus regional anesthesia
Mini-C arm
Kirschner wires (0.045 in, 0.035 in, 0.028 in)
Modular screws (1.5 mm, 1.3 mm, 1.1 mm)
Technique Unicondylar fractures are approached from a midaxial approach on the side of the fracture by
retracting the extensor tendon dorsally (Fig. 6-16). The ipsilateral transverse retinacular ligament of the extensor
is released, and the conjoined lateral band together with the central extensor tendon is elevated dorsally to
expose the fractured condyle. A dorsal capsulotomy affords visual confirmation of articular reduction. A fine
dental pick or K-wire is passed into the condyle to assist with manipulation. Preservation of the collateral
ligament origin minimizes the risk of osteonecrosis. Once the fracture is adequately reduced, the wire is
advanced transversely across the fracture. Reduction can be stabilized with a tenaculum forceps. A lag screw is
passed proximal to the K-wire. The K-wire is then removed and exchanged for a subchondral lag screw, which
should avoid incarceration of the collateral ligament. A minimum of two wires/screws are used for rotational
stability.
Coronal condylar fractures remain challenging. Displaced fractures lead to joint instability and articular malunion
when left untreated. Preoperative CT scan assists in selection of surgical approach (i.e., dorsal versus volar).
The fragment is gently manipulated back into position. K-wire or screw fixation is selected based on fragment
size and comminution.
Open reduction of bicondylar fractures requires visualization of the distal articular surface. At the PIP joint, a
curved dorsal skin incision is used and the extensor mechanism is mobilized either by making an incision
between the lateral and central slip on either side, or by elevating the extensor mechanism and creating a distally
based V-shaped flap with the apex of the V situated at the proximal third of the proximal phalanx (i.e., reverse
Chamay) (15). At the DIP joint, the fracture fragments are accessed
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on each side of the terminal extensor tendon. A transverse capsulotomy will allow visualization of the joint. The
articular surface is reduced and provisionally stabilized with size appropriate K-wires. The articular fragments are
then stabilized to the shaft with an oblique K-wire (Fig. 6-17). While this fixation will maintain reduction, it will not
permit early motion and consideration must be given to stable internal fixation with a plate—either a dorsal T-
plate or a laterally applied mini-condylar plate. Although insertion of a lateral condylar plate is technically more
challenging, it causes least interference with the extensor mechanism. Laterally applied modular fixed angle
plates have begun to replace mini-condylar blade plates. The extensor tendon interval is repaired with
nonabsorbable sutures.
FIGURE 6-16 A: Preoperative radiographs demonstrate malrotated ulnar condylar fracture. CT was utilized in
this case to better define the fracture plane. B: A dorsal curvilinear incision is utilized, followed by elevation of a
full-thickness cutaneous flap. C: Division of the transverse retinacular ligament. D: Division of the transverse
retinacular ligament allows retraction of the ipsilateral conjoined lateral band and central extensor followed by
dorsal capsulotomy and fracture mobilization. E: Complete malrotation of the condylar fracture fragment on the
ipsilateral collateral ligament is seen. F: Articular reduction and fixation with two modular hand screws.
FIGURE 6-16 (Continued) G: Tenodesis demonstrates restoration of the digital cascade. H: Final postoperative
radiographs. I: Final clinical outcome at 6 months' follow-up.
FIGURE 6-17 K-wire fixation of bicondylar proximal phalangeal fracture.
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FIGURE 6-18 A: Complex complete articular fracture of the head of the proximal phalanx. B: Silicone implant
arthroplasty performed as the articular surface was not amendable to reconstruction.
In extensively comminuted phalangeal head fractures, external fixation is used when ligamentotaxis effects
relative joint congruency. Arthroplasty may be considered in elderly low-demand individuals when the articular
surface is not reconstructable or poor bone quality precludes stable fixation (Fig. 6-18).
Pearls and Pitfalls

Preservation of the collateral ligament origin minimizes the risk of osteonecrosis
Screw length is critical to avoid collateral ligament (i.e., sagittal plane condylar fractures) and flexion tendon
impingement (i.e., coronal plan condylar fractures)
Selection of extensor tendon intervals is planned to afford optimal articular visualization.
Following stable fixation, active and active-assisted motion and reverse blocking exercises are initiated within
the first postoperative week.
A hand-based intrinsic plus splint is used in between range of motion sessions.
PHALANGEAL BASE FRACTURES

Dorsal Base Fractures
Isolated dorsal base fractures occur in the middle phalanx and distal phalanx and represent avulsion fractures of
the central slip and terminal extensor tendons, respectively. At the PIP joint, these injuries may be a radiographic
surrogate for a volar dislocation that has underwent spontaneous reduction. Treatment of the injury depends on
radiographic alignment of the fragment following joint reduction and splinting in terminal extension. Operative
treatment is indicated if the fragment remains displaced by 2 mm or more, if the joint is incongruent due to
angulation of a large fragment, or if there is joint subluxation.
Dorsal articular fractures at the DIP joint (i.e., mallet fractures) are common. Large fragments may result in joint
instability and subluxation and require reduction and fixation (transarticular, dorsal block pinning, or formal
ORIF). When there is no subluxation, nonoperative treatment is usually preferred. Articular remodeling can be
seen, but patients are counseled regarding post-traumatic arthrosis. Large fracture fragments with resultant volar
articular subluxation are amendable to ORIF.
Small nondisplaced/minimally displaced dorsal base fractures not associated with a volar PIP dislocation or
extensor lag may be treated with a short arc of motion protocol (16) with the understanding that close serial
clinical follow-up is needed to ensure that an extensor lag does not develop.
Pinning the PIP joint in full extension will usually restore satisfactory alignment when the avulsion fragment is
small and allow for the central slip avulsion fragment to unite. Open reduction and screw fixation via a dorsal
approach may be considered for displaced, large fragments with residual joint subluxation (Fig. 6-19). An
alternative method of fixation consists of a cerclage wire applied through transverse metaphyseal drill holes in
the base of the middle phalanx and passed deep to the central slip (Fig. 6-20). Supplemental transarticular K-
wire for 3 to 4 weeks is necessary to protect the fixation.
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FIGURE 6-19 A: Large, displaced central slip avulsion fracture with resultant volar rotatory subluxation of the
PIP B: ORIF via dorsal approach utilizing modular screw fixation. Postoperative rehabilitation consisted of an
active short arc of motion protocol with progressive reduction of the PIP flexion block.
FIGURE 6-20 A: Severe digital crush injury with dysvascular digit and (B) open, large, displaced central slip
avulsion fracture. C: Postoperative PA and lateral radiographs following ORIF with cerclage wire transarticular
fixation. Revascularization was performed following bony fixation. D: Final clinical outcome.
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Volar Lateral Fractures
Fractures of the lateral volar base of the proximal or middle phalanx result from collateral avulsion and may be
associated with joint dislocation. Minimally displaced lateral corner fractures that do not compromise joint stability
or result in an incongruous articular surface can be treated by splinting followed by early protected motion.
Displaced lateral corner fractures that compromise joint stability are treated with internal fixation. A palmar
approach to the joint involves a chevron incision centered over the joint flexion crease. The interval between the
neurovascular bundle and the flexor tendon sheath is developed. The cruciate-synovial window between the A2
and A4 pulleys is reflected. The flexor tendons are reflected laterally exposing the volar plate. The volar plate is
then incised and reflected distally. The fragment is elevated and reduced. Tension band fixation (Fig. 6-21) and
screw fixation (Fig. 6-22) provide stable fixation.
FIGURE 6-21 A: Index finger MCP joint RCL bony insertional avulsion. B: ORIF using figure-of-eight tension
band technique.
FIGURE 6-22 A: Small finger open dorsal PIP fracture-dislocation. B: Under digital anesthetic, the open wound
was first irrigated followed by closed reduction. Postreduction radiographs demonstrate a large displaced and
malrotated volar-radial marginal fracture at the base of the middle phalanx. C: Open reduction is performed via
palmar exposure through the open palmar wound. The A2 and A4 pulleys are preserved, and the flexor tendons
are retracted ulnarward. The volar plate remains attached to the volar-radial marginal fracture fragments
(forceps). The metaphyseal donor site at the volar radial margin of the middle phalangeal base is visualized
(arrow).
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FIGURE 6-22 (Continued) D: The articular fragments are anatomically reduced and internal fixation performed
with a 1.3-mm modular hand screw while preserving the volar plate attachment on the articular fragment (arrow).
E: The volar plate is repaired to the ulnar critical corner (dental probe) following fixation of the volar radial
margin. Postoperative rehabilitation included early active motion with gradual reduction of a dorsal block splint.
F: Final postoperative radiographs demonstrate preservation of joint space and maintenance of a congruous
reduction. Full composite flexion was achieved. A small residual PIP flexion contracture did not require further
treatment.
FIGURE 6-23 PIP joint palmar lip fracture stability is determined by the size of the palmar articular fragment size.
Plateau Fractures
Compression injuries can cause radial or ulnar plateau impaction at the base of the middle phalanx or proximal
phalanx. The radiographic findings may be subtle. Clinical exam under local anesthesia will demonstrate angular
deformity as the phalangeal condyle engages the area of articular impaction. These injuries require open
reduction from a dorsal or lateral approach with elevation of the articular fragment and bone grafting of the
metaphyseal void. An additional buttress plate should be considered if the fracture is felt to be unstable or if
there is diaphyseal extension (17).
Volar Central Fractures and Fracture-Dislocations

Palmar lip fractures are classified based on the stability of the interphalangeal joint, which is predicated on the
size of the articular marginal fracture (Fig. 6-23). In most cases, the PIP remains stable with small palmar lip
avulsion fractures (less than 30% articular surface) and are treated with early protected motion protocols.
Occasionally, the marginal fracture may be significantly displaced or malrotated, but the PIP joint remains stable.
Displaced volar marginal fractures may limit interphalangeal joint flexion and may be excised when joint stability
is not compromised. Extrusion of the fragment into the flexor sheath has been described (18).
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Cadaveric analyses have demonstrated that when the articular fragment measures greater than 40% of the
articular surface, the interphalangeal joint becomes unstable as the insertional footprint of the collateral
ligaments remains with the volar articular fragment(s) (19). For larger fractures with associated dorsal instability,
closed reduction by traction, volar translation, and flexion of the PIP joint may be successful if performed acutely
(i.e., within a few days after injury). It is important to document under fluoroscopic guidance the joint position at
which dorsal subluxation recurs. If more than 30 degrees of flexion is necessary to maintain a congruous
reduction, stabilization is recommended.
Extension block splinting (20) is applicable to cases when a closed, congruous reduction can be achieved.
The dorsal block splint prevents extension of the PIP joint to the point of re-dislocation, while permitting PIP joint
flexion. Custom splinting is initiated at 10 degrees more than the angle of PIP stability. The amount of flexion is
reduced on a weekly basis by about 25% and full extension is delayed for about 4 weeks followed by buddy
taping for an additional 2 weeks. Acceptable outcomes have been achieved with short periods of immobilization
with the finger in as much as 50 to 60 degrees of flexion. Close follow-up with frequent radiographic examination
is warranted to ensure that congruous reduction is maintained.
Extension block pinning (21) is used when the reduced PIP cannot be adequately stabilized in a dorsal block
splint. The PIP joint is reduced by applying manual traction and placing the joint into maximal possible flexion. A
smooth Kirschner wire is then introduced percutaneously to engage the distal articular surface of the proximal
phalanx and advanced in an intra-medullary fashion to engage the volar cortex of the proximal phalanx. Pin
placement should avoid incarceration of the central slip. Gentle active range of motion exercise is initiated, and
the K-wire is removed at 3 to 4 weeks.
Closed reduction and percutaneous fixation of unstable solitary volar central articular fractures has been
described with parallel percutaneous K-wires (22).
ORIF of unstable fracture dislocations of the PIP joint is reserved for fracture-dislocations with a large,
noncomminuted volar articular fragment amendable to screw fixation or in cases with delayed presentation when
closed reduction or traction techniques are unsuccessful. Reduction and stabilization of the volar lip fracture of
the middle phalanx restores adequate stability to allow early active motion and rehabilitation (23,24,25).
A palmar exposure using either Bruner or midaxial incisions is performed from the proximal digital crease to the
DIP flexion crease. The flexor tendon sheath is opened between the A2 and A4 pulleys and the flexor tendons
retracted. Often the sheath is ruptured in this region and can be excised without significant functional loss. The
volar plate is mobilized by releasing its lateral attachments to the collateral ligaments and joint is gently “shot-
gunned” (Fig. 6-24). The articular fragment is reduced and provisionally held size-appropriate K-wires. The
reduction is assessed fluoroscopically, and the K-wires can then be sequentially exchanged for modular hand
screws (usually 2 to 3
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screws ranging from 1.1 mm to 1.3 mm). Rarely, a buttress plate for comminuted fractures may be needed. In
chronic cases with an irreducible joint, the attachments of the collateral ligaments to the base of the middle
phalanx are partially released in a volar to dorsal direction and the digit is gently hyperextended until it is fully
“shotgunned.” The volar fragment is then fully visualized. Small comminuted fragments are removed and the
major volar fragment is elevated, reduced and held either with a circumferential wire loop or with lag screws
passed from volar to dorsal (26).
FIGURE 6-24 ORIF of large palmar lip fracture is performed through a volar exposure.
When the volar central base is comminuted and cannot be stabilized, volar plate interpositional arthroplasty
(VPA) (Fig. 6-25) to resurface the volar articular surface of the middle phalanx is indicated when less than 40%
of the joint is involved (27). Dionysian and Eaton have reported on mid-term outcomes following VPA (28). At a
mean of 11.5 years postoperatively, patients treated with VPA within 4 weeks of injury attained a mean 85
degree active arc of PIP motion compared to 65 degrees in patients treated with VPA at greater than 4 weeks.
Four of seventeen patients showed some degree of joint narrowing at the follow-up examination. Volar central
articular fractures of the DIP are treated similarly with closed reduction and transarticular fixation (Fig. 6-26),
ORIF (Fig. 6-27), or VPA based on reducibility, joint stability, and fracture size and comminution. The
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integrity of the flexor digitorum profundus (FDP) is examined as closed FDP avulsions are seen in conjunction
with volar rim and comminuted distal phalangeal base fractures (i.e., Leddy-Packer injury variants).
FIGURE 6-25 A: A radially based volar flap is utilized. B: A cruciate-synovial window between A2 and A4 is
utilized, and flexor tendons are retracted. The collateral ligaments are released proximally. The volar plate is
reflected proximally. The PIP joint is then “shotgunned.” C: The base of the middle phalanx is then debrided to
create a symmetric transverse groove. Drill holes with 0.045 inch K-wires are placed at the periphery of the
defect. D: 2-0 Prolene suture is passed through distal edge and the suture limbs are then passed volar to dorsal
using straight thin Keith needles. E: The PIP joint is transfixed in 20 to 30 degrees of flexion. The volar plate is
then advanced and the Prolene sutures are tied dorsally over a pullout button. The critical corners of the three-
dimensional ligamentous box supporting the PIP joint is restored when the volar plate is sutured to the collateral
ligament insertions.
FIGURE 6-26 A,B: DIP dorsal fracture-subluxation secondary to volar marginal fracture. Note the dorsal “V-
sign.” C,D: Closed reduction and transarticular fixation. E,F: Articular remodeling noted at latest follow-up.
FIGURE 6-27 A: Complex FDP avulsion with concomitant DIP volar marginal fracture. Note the additional
osseous fragment at the A4 level. B: Palmar exposure is performed. Traumatic rupture of the A5 pulley is noted.
The displaced malrotated volar articular fragment is seen as is the incarcerated FDP avulsion fragment beneath
the A4 pulley. C: The volar articular fragment left attached to the volar plate, reduced, and secured with a
bicortical modular hand screw. The FDP stump is seen emerging from the A4 pulley. D: The FDP is then
advanced to its footprint in the distal phalanx and secured with a pullout suture tied over the dorsal nail plate.
Hemi-hamate osteochondral autograft (HHA) reconstruction of the volar base of the middle phalanx has
augmented the armamentarium of treatment options for previously irreconstructable articular injuries (29,30,31).
HHA is indicated for comminuted, unstable PIP palmar lip fractures and fracture-dislocations. Comminuted,
lateral plateau fractures that cause angular deformity and are not large enough for ORIF are also appropriate for
HHA. HHA is also a satisfactory salvage option for patients who have redislocated after external fixation, ORIF,
or VPA (Fig. 6-28). At a mean 4.5 years following HHA, Calfee et al. (31) reported a mean 70-degree arc of PIP
motion with a 19-degree flexion contracture, and the mean DASH score indicated little functional impairment.
HHA is contraindicated when there is advanced articular changes already present on the head of the proximal
phalanx. In these cases, arthrodesis or implant arthroplasty are considered.
FIGURE 6-28 A: Preoperative radiographs demonstrating comminuted impacted volar central and lateral plateau
articular fractures of the middle phalanx with dorsal subluxation of the PIP joint (V-sign; arrow). B: Intraoperative
exposure as previously described. C: Postoperative radiographs following HHA demonstrating restoration of
articular congruency.
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Various external fixation constructs are used for unstable, acute, comminuted volar central fractures, pilon
fractures, and subacute/chronic PIP fracture-subluxations. Continuous dynamic skeletal traction can be applied
to the digit through several transosseous proximal and middle phalangeal K-wire configurations and with the
addition of force-coupling wires (32,33). Dynamic fixation constructs allow some degree of active motion to allow
the concave articular surface to remodel around the convex condyles of the proximal phalanx while the joint
remains unloaded from compressive and shear forces. Static external fixators also may be used (Fig. 6-29). If
adequate reduction of the articular surface of the middle phalanx is not achieved by traction alone, the articular
surface can be manipulated percutaneously or by open reduction. The fragments are then stabilized with multiple
small K-wires, and traction is then applied (34). The variable configurations are all based on the concept of joint
reduction via ligamentotaxis around the articular base.
FIGURE 6-29 A: PIP joint pilon fracture with associated metadiaphyseal fracture. B: Ligamentotaxis through
ulnar-based unilateral static external fixator restores articular congruency and metadiaphyseal alignment. C:
Osseous union with residual central articular defect at the base of the middle phalanx. D: Satisfactory clinical
and functional outcome is achieved.
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REFERENCES
1. Belsky MR, Eaton RG, Lane LB: Closed reduction and internal fixation of proximal phalangeal fractures. J
Hand Surg Am 9(5): 725-729, 1984.
2. Freeland AE, Sud V, Lindley SG: Unilateral intrinsic resection of the lateral band and oblique fibers of the
metacarpophalangeal joint for proximal phalangeal fracture. Tech Hand Up Extrem Surg 5(2): 85-90, 2001.
3. Ouellette EA, Dennis JJ, Latta LL, et al.: The role of soft tissues in plate fixation of proximal phalanx
fractures. Clin Orthop Relat Res 418: 213-218, 2004.
4. Lu WW, Furumachi K, Ip WY, et al.: Fixation for comminuted phalangeal fractures. A biomechanical study
of five methods. J Hand Surg Br 21(6): 765-767, 1996.
5. Roth JJ, Auerbach DM: Fixation of hand fractures with bicortical screws. J Hand Surg Am 30(1): 151-153,
2005.
6. Page SM, Stern PJ: Complications and range of motion following plate fixation of metacarpal and
phalangeal fractures. J Hand Surg Am 23(5): 827-832, 1998.
7. Ruchelsman DE, Mudgal CS, Jupiter JB: The role of locking technology in the hand. Hand Clin 26(3): 307-
319, 2010.
8. Al-Qattan MM: Phalangeal neck fractures in children: classification and outcome in 66 cases. J Hand Surg
Br 26: 112-121, 2001.
9. Waters PM, Taylor BA, Kuo AY: Percutaneous reduction of incipient malunion of phalangeal neck
fractures in children. J Hand Surg Am 29(4): 707-711, 2004.
10. Puckett BN, Gaston RG, Peljovich AE, et al.: Remodeling potential of phalangeal distal condylar
malunions in children. J Hand Surg Am 37(1): 34-41, 2012.
11. Tada K, Ikeda K, Tomita K: Malunion of fractures of the proximal phalangeal neck in children. Scand J
Plast Reconstr Surg Hand Surg 44(1): 69-71, 2010.
12. Cornwall R, Waters PM: Remodeling of phalangeal neck fracture malunions in children: case report. J
Hand Surg Am 29(3): 458-461, 2004.
13. Weiss APC, Hastings H: Distal unicondylar fractures of the proximal phalanx. J Hand Surg 18A: 594-599,
1993.
14. Chin KR, Jupiter JB: Treatment of triplane fractures of the head of the proximal phalanx. J Hand Surg Am
24(6): 1263-1268, 1999.
15. Chamay A: A distally based dorsal and triangular tendinous flap for direct access to the proximal
interphalangeal joint. Ann Chir Main 7(2): 179-183, 1988.
16. Evans RB: Early active short arc motion for the repaired central slip. J Hand Surg Am 19(6): 991-997,
1994.
17. Strickler M, Nagy L, Buchler U: Rigid internal fixation of basal fractures of the proximal phalanges by
cancellous bone grafting only. J Hand Surg 26B: 455-458, 1999.
18. Failla JM: Extrusion of fracture fragment into flexor sheath following proximal interphalangeal joint
fracture-dislocation: a case report. J Hand Surg Am 21(2): 253-255, 1996.
19. Hastings H II, Carroll C IV: Treatment of closed articular fractures of the metacarpophalangeal and
proximal interphalangeal joints. Hand Clin 4(3): 503-527, 1988.
20. McElfresh EC, Dobyns JH, O'Brien ET: Management of fracture-dislocation of the proximal
interphalangeal joints by extension-block splinting. J Bone Joint Surg Am 54(8): 1705-1711, 1972.
21. Viegas SF: Extension block pinning for proximal interphalangeal joint fracture dislocations: preliminary
report of a new technique. J Hand Surg 17A: 896-901, 1992.
22. Vitale MA, White NJ, Strauch RJ: A percutaneous technique to treat unstable dorsal fracture-dislocations
of the proximal interphalangeal joint. J Hand Surg Am 36(9): 1453-1459, 2011.
23. Hamilton SC, Stern PJ, Fassler PR, et al.: Mini-screw fixation for the treatment of proximal
interphalangeal joint dorsal fracture-dislocations. J Hand Surg Am 31(8): 1349-1354, 2006.
24. Grant I, Berger AC, Tham SK: Internal fixation of unstable fracture dislocations of the proximal
interphalangeal joint. J Hand Surg Br 30(5): 492-498, 2005.
25. Lee JY, Teoh LC: Dorsal fracture dislocations of the proximal interphalangeal joint treated by open
reduction and interfragmentary screw fixation: indications, approaches and results. J Hand Surg Br 31(2):
138-146, 2006.
26. Weiss APC: Cerclage fixation for fracture dislocation of the proximal interphalangeal joint. Clin Orthop
Relat Res 327: 21-28, 1996.
27. Eaton RG, Malerich MM: Volar plate arthroplasty of the proximal interphalangeal joint: a review of ten
years' experience. J Hand Surg Am 5(3): 260-268, 1980.
28. Dionysian E, Eaton RG: The long-term outcome of volar plate arthroplasty of the proximal interphalangeal
joint. J Hand Surg Am 25(3): 429-437, 2000.
29. Williams RM, Kiefhaber TR, Sommerkamp TG, et al.: Treatment of unstable dorsal proximal
interphalangeal fracture/dislocations using a hemi-hamate autograft. J Hand Surg Am 28(5): 856-865, 2003.
30. Williams RM, Hastings H II, Kiefhaber TR: PIP Fracture/dislocation treatment technique: use of a hemi-
hamate resurfacing arthroplasty. Tech Hand Up Extrem Surg 6(4): 185-192, 2002.
31. Calfee RP, Kiefhaber TR, Sommerkamp TG, et al.:. Hemi-hamate arthroplasty provides functional
reconstruction of acute and chronic proximal interphalangeal fracture-dislocations. J Hand Surg Am 34(7):
1232-1241, 2009.
32. Slade reference; Schenck RR: Dynamic traction and early passive movement for fractures of the proximal
interphalangeal joint. J Hand Surg 11A: 850-858, 1986.
33. Suzuki Y, Matsunaga T, Sato S, et al.: The pins and rubbers traction system for treatment of comminuted
intraarticular fractures and fracture-dislocations in the hand. J Hand Surg 19B: 98-107, 1994.
34. Sarris I, Goitz RJ, Sotereanos DG: Dynamic traction and minimal internal fixation for thumb and digital
pilon fractures. J Hand Surg 29A: 39-43, 2004.
Chapter 7
Operative Strategies for Basilar Thumb Fractures: Rolando's and
Bennett's Fractures
Michael D. Wigton
Joelle Tighe
Mark E. Baratz
Injuries to the base of the thumb metacarpal typically present with two patterns: Bennett's fracture or Rolando's
fracture. Both fractures are characterized by inherent instability due to the ligamentous and tendinous insertions
crossing the thumb carpometacarpal (CMC) joint. Additionally, these fractures involve the surface of the base of
the thumb metacarpal (Fig. 7-1). Bennett's fracture was first described in 1885 by Dr. E.H.
Bennett, in an address to the British Medical Association (1). This pattern involves a volar (palmar)-ulnar fracture
fragment that remains attached to the tubercle of the trapezium by virtue of the anterior oblique ligament (AOL)
(Fig. 7-2). The base of the metacarpal is subluxated in a proximal, radial, and supinated position due to the pull
of the abductor pollicis longus. The radial subluxation of the metacarpal base leads to an adducted posture of
the thumb metacarpal. Rolando's fracture involves an additional radial fragment with or without comminution of
the base of the first metacarpal (2).
Historically, nonoperative management was the treatment of choice in fractures of the base of the thumb
metacarpal. In 1990, Livesley published a 26-year follow-up of nonoperatively treated Bennett's fractures in
which 100% had decreased range of motion and grip strength (3). Since then, operative treatment has been
favored.
Surgical indications include displaced and/or unstable fractures or articular displacement greater than 2 mm.
(Articular displacement alone is a debatable topic in the literature as there are conflicting reports of the long-term
functional significance of joint degeneration.) The current standard of care in most cases is operative as few
fractures of the base of the first metacarpal are neither stable nor nondisplaced. The CMC joint is a saddle
articulation with concavity in the volar-dorsal plane and convexity in the radial-ulnar plane. This joint has an
inherently wide range of motion in all planes allowing opposition, pinch, and grip functions of the thumb; this
results in fracture instability. The AOL or beak ligament (Fig. 7-2) prevents volar subluxation of the metacarpal
and accounts for the relative stability of the constant fragment in a Bennett's fracture. The abductor pollicis
longus (APL) (Fig. 7-1) crosses the CMC joint and inserts on the proximal and radial aspect of the first
metacarpal creating a deforming force in both a Bennett's and Rolando's fracture pattern. The APL accounts for
the radial and dorsal translation of the metacarpal in Bennett's fracture and the displacement of the radial
fracture fragment(s) in Rolando's fracture. The extensor pollicis
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longus (EPL) contributes to the dorsal and proximal migration of the metacarpal. Adduction of the metacarpal is
seen most significantly with Bennett's fracture and is caused by the adductor pollicis (AdP) insertion at the
proximal, ulnar base of the proximal phalanx. Together, these forces create the classic deformities seen.
FIGURE 7-1 Anatomical dissection of left thumb showing the first CMC joint with the APL insertion with the
direction of pull indicated.
FIGURE 7-2 The left CMC joint is demonstrated with the palmar/volar (right) and dorsal (left) ligaments outlined.
Nonoperative treatment is an option for stable, nondisplaced fractures. Cast immobilization with weekly close
radiographic follow-up over the first 4 weeks postinjury is recommended as these fractures may have tendency
for displacement even if initially nondisplaced.
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The mechanism of injury typically involves an axial load to the thumb, often occurring during a sporting event,
fall, or higher-energy trauma such as a motor vehicle collision. Physical examination will reveal pain, swelling,
and ecchymosis about the base of the thumb metacarpal. Swelling can be significant, resulting in distortion of
usually palpable landmarks.
Radiographic evaluation includes posteroanterior and lateral views of the thumb (Figs. 7-3 and 7-4). Views
specific for the thumb CMC joint may also be useful such as Robert's view (4) and Bett's or Gedda's view (5,6).
These views may be difficult to obtain in the acutely traumatized hand. Preoperative computed tomography scan
is reserved for chronic injuries to assess deformity, union, and the presence of arthritic changes.
FIGURE 7-3 PA radiograph and clinical photograph of the normal CMC joint.
FIGURE 7-4 Lateral radiograph and clinical photograph of the normal CMC joint.
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If closed reduction and pinning is contemplated, we prefer to attempt this in the first week following the injury to
facilitate exposure and reduction. Initially, the fracture is immobilized in a thumb spica splint and the limb is
elevated.
The primary operative goal is a stable CMC joint with the articular surface of the metacarpal that is aligned with
the trapezium. The base of the radial cortex of the metacarpal typically forms a “V” with the radial cortex of the
trapezium. A “broken V” is seen with fracture-subluxation of the metacarpal. Restoration of the “V” indicates
correction of the subluxation (Figs. 7-5 and 7-6). A perfect articular surface is not always possible, nor does it
seem to alter the short- or long-term outcome. A number of techniques have been described for both Rolando's
and Bennett's fractures.
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Closed reduction and percutaneous pinning, open reduction and internal fixation, traction pinning, and external
fixation may be viable options in either fracture pattern.
FIGURE 7-5 Line drawing representing the radial “v” as seen in the anatomically normal CMC articulation (left).
In Bennett's fracture, the “v” is broken with CMC subluxation (right).
FIGURE 7-6 Radiograph showing the typical appearance of a Bennett's fracture with the volar ulnar constant
fragment; the metacarpal is subluxated radial, proximal, and supinated. The radiographic “v” representing the
reduced radial articulation is broken demonstrating joint subluxation.
We prefer closed reduction and pinning for both injury patterns. Open reduction and internal fixation is reserved
for fracture-dislocations where we cannot get reasonable alignment of the metacarpal base with respect to the
trapezium or in Bennett's fractures or where there are two large fracture fragments.
SURGICAL TECHNIQUE
The patient is placed in a supine position. We prefer regional anesthesia with a proximal block (axillary). The arm
is positioned at 90 degrees from the body on an operating hand table. Intraoperative fluoroscopy is used for
assessment of fracture reduction and fixation.
Closed Reduction With Percutaneous Pinning

Bennett's Fracture Closed reduction and percutaneous pinning are preferred in the majority of the Bennett's
fracture during the acute phase provided the articular reduction is less than 1 to 2 mm of articular step-off (7,8).
Closed reduction has been described with several methods including the passive screw-home technique. This
technique takes advantage of an intact dorsal-radial ligament (9). The thumb is opposed and maximally
pronated. The hitchhiker's position should be avoided as extension of the metacarpophalangeal (MCP) joint may
lead to malreduction.
Several pin configurations have been described. A transarticular technique as described by Wagner (10) has
resulted in acceptable long-term functional outcomes but may have a higher rate of adduction deformity (11).
This technique places one retrograde wire from the metacarpal base crossing the CMC joint into the trapezium. A
second wire is placed from the intact metacarpal base into the volar ulnar fragment. Transmetacarpal pinning is
also described with acceptable radiographic and functional outcomes despite the development of arthritis
radiographically (12,13). This technique is particularly useful in fracture patterns that are axially unstable after
reduction.
Our preferred technique begins with traction, abduction, and pronation of the metacarpal. This is done with the
MCP flexed and with pressure over the dorsal and radial aspect of the metacarpal base. A 0.045″ wire is then
introduced into the base of the thumb metacarpal at the junction of the glabrous and nonglabrous skin. It is
advanced into the far cortex of the index metacarpal. Intraoperative fluoroscopy is used to confirm that the “V
sign” is restored. A second pin is placed from the base of the thumb metacarpal into the trapezium. If the CMC
joint is incongruent or the articular reduction is outside of acceptable parameters, a second attempt at reduction
or an open reduction can be performed. Following successful closed reduction and pinning, the wires are cut
outside of the skin. A well-padded thumb spica plaster splint is applied, and the hand is elevated until the
swelling resolves. The patient is encouraged to begin immediate active motion of the fingers. At two weeks, the
splint is converted to a thumb spica cast with the thumb interphalangeal (IP) joint free to allow for active motion of
the thumb IP joint. The cast and pins are removed at 4 weeks. The patient is then provided with a removable
hand-based thumb spica splint for driving and light lifting for an additional 3 to 4 weeks. There are no clear
guidelines for the duration of immobilization. The injury involves both a fracture and injury to the ligaments
supporting the thumb CMC joint, and immobilization is intended to encourage healing of both elements.
Rolando's Fracture Rolando's fracture involves at least two distinct articular fragments. When possible, we
prefer indirect reduction with suspension of the thumb metacarpal by two parallel wires placed in the index
metacarpal. The reduction is performed, as above, with traction, abduction, and pronation of the metacarpal. The
MCP joint is held in a flexed position. A 0.045″ wire is then introduced into the base of the thumb metacarpal at
the junction of the glabrous and nonglabrous skin. It is advanced into the far cortex of the index metacarpal.
Intraoperative fluoroscopy is used to confirm that the “V sign” is restored. A second pin is placed parallel to the
first pin.
Open Reduction and Internal Fixation

Bennett's Fracture Open treatment of Bennett's fracture is considered when closed reduction fails to (a) reduce
articular displacement within acceptable parameters or (b) restore proper metacarpal-trapezial alignment. There
is no evidence, that we are aware, supporting open versus closed treatment. To emphasize, the importance of
articular reduction is debatable, and therefore, the decision to open a Bennett's fracture should not be based on
the ability to perfectly reduce the
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articular displacement alone (13). Our approach is admittedly arbitrary. We consider open treatment when closed
reduction results in an unacceptable reduction of the articular surface or incomplete reduction of the “V sign.” We
will also consider ORIF when there is a large ulnar fragment that will allow for solid interfragmentary fixation and
joint reduction (Fig. 7-7).
When open treatment is performed, a Wagner approach is used through an incision on the dorsalradial aspect
along the glabrous border over the CMC joint between the APL/EPB and the thenar muscles. This is curved
volarly to the distal wrist crease up to the flexor carpi radialis tendon. Care is taken to avoid injury to branches of
the superficial branch of the radial nerve and palmar cutaneous branch of the median nerve. The thenar muscles
are carefully reflected subperiosteally from the volar aspect of the trapezium and proximal metacarpal. A
longitudinal capsulotomy is then made to expose the CMC joint. Every attempt should be made to preserve all
soft-tissue attachments to fracture fragments (Fig. 7-8).
FIGURE 7-7 PA radiograph demonstrating a Bennett's fracture.
FIGURE 7-8 Intraoperative clinical photograph showing the Wagner approach for ORIF of a Bennett's fracture.
The two large articular fragments are seen within the wound.
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FIGURE 7-9 Clinical intraoperative photograph showing ORIF of a Bennett's fracture in progress. K-wires have
been placed provisionally after anatomic reduction of the metacarpal articular surface.
FIGURE 7-10 The previously placed provisional K-wires have been exchanged for interfragmentary screws as
definitive fixation.
The articular surface is reduced, and the reduction is maintained with two parallel wires, 0.035″ or 0.045″,
depending on the size of the fracture fragments (Fig. 7-9). The wires are removed one at a time and replaced
with a 1.0-mm screw if a 0.035″ wire was used or a 1.5-mm screw if a 0.045″ wire was used (Fig. 7-10).
Rolando's Fracture The degree of articular comminution associated with Rolando's fracture may be difficult to
assess. In most cases, we use closed reduction and “suspension” as the preferred form of treatment. Following
traction, abduction, and pronation, two 0.045″ pins are passed from the base of the thumb metacarpal into the
base of the index metacarpal. If the reduction is unacceptable, the joint is exposed through a Wagner approach.
Fracture fragments can be reduced and pinned or stabilized with interfragmentary screws.
An alternative approach is open reduction with T-plate fixation.
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Pearls and Pitfalls
These injuries result from the combined failure of bone and the supporting ligaments.
Bennett's fracture and Rolando's fracture are sufficiently uncommon that we don't have strong evidence to
support one therapeutic approach over the other.
Conventional wisdom suggests that alignment of the metacarpal with respect to the trapezium is as, or more,
important than anatomic restoration of the articular surface.
Restoration of the radiographic “V sign” of the radial trapeziometacarpal joint should guide the accuracy of
CMC reduction.
Closed reduction with percutaneous pinning of the thumb to the index metacarpal is the preferred first line of
treatment for Bennett's fracture.
Percutaneous pin placement at the junction of the glabrous and nonglabrous skin avoids nerve injury.
Open treatment is reserved for fractures where acceptable reduction and alignment are not restored with
closed methods or in Rolando's fracture where there is a large ulnar fragment.
0.035″ and 0.045″ pins can be exchanged for 1.0 mm and 1.5 mm screws, respectively.
Bennett's Fracture
The splint is removed for pin site inspection at 10 to 14 days and is replaced with a thumb spica cast. The time of
immobilization is arbitrary as the goal is to achieve both union of the bone and stability via the surrounding soft
tissues. Our approach is to remove the pins at 6 weeks and apply a handbased thumb spica splint. At 8 weeks,
the splint is removed for gentle use. By 10 to 12 weeks, the splint is discontinued. This approach is conservative.
Some authors have advocated early motion in cases where ORIF with screw fixation has been used. At this time,
we are unable to state whether these two techniques result in equivalent outcomes.
Rolando's Fracture
The postoperative management for Rolando's fracture, in our hands, is identical to that for the Bennett's fracture.
REHABILITATION
Therapy is typically initiated between 10 and 12 weeks after surgical treatment. The most common issues are
adduction contracture, thumb IP joint and CMC stiffness, and weakness of pinch and grip. A web space static
progressive stretching splint can be fabricated for part-time use. The therapist can design a stretching and
strengthening protocol.
RESULTS
Bennett's Fracture
A number of studies have demonstrated acceptable outcomes with each of the described treatments. The
resounding theme relates to the rate of posttraumatic arthritis seen and the lack of correlation with anatomic
articular reduction (7,11,12,14). Lutz et al. reported on 46 Bennett's fractures treated with either closed
reduction and pinning or open reduction and internal fixation with lag screws. These patients were not
randomized; rather, they were treated with an algorithm where closed reduction was abandoned for open
reduction when articular displacement remained greater than 1 mm. They found a slightly higher rate of
adduction deformity with closed treatment; however, there was no correlation with pain or functional
outcome.
Leclère et al. reported on 28 patients treated with open reduction and internal fixation in retrospective
review with an average of 83 months' follow-up. Radiographs were evaluated at 4 months postoperatively
and final follow-up to determine residual articular gapping or step-off and the presence of arthritis. In this
small series, no correlation was seen between articular deformity and arthritis. They suggested that the
etiology of arthritis in a joint such as the trapeziometacarpal joint may be more degenerative than
posttraumatic.
Rolando's Fracture
Only a few studies exist evaluating the outcomes of treatment of Rolando's fracture. van Nierkerk and
Ouwens reported their series of thumb metacarpal base fractures. Seven of the twenty three
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patients were classified as having Rolando's fracture (15). Functional outcomes were acceptable in all
patients, but 4 of 5 patients to develop advanced arthritic changes were those with Rolando's fracture. All
Rolando's fractures in this series were treated by closed means.
Langhoff et al. reported on a series of 17 Rolando's fractures treated with closed or open reduction and pin
fixation based on ability to achieve articular reduction (16). Articular reduction was graded postoperatively,
and functional outcome was assessed at a mean final follow-up of 5.8 years. No correlation was found
between quality of reduction and function, range of motion, arthritic changes, or pinch or grip strength.
Two recent studies reported on outcomes of external fixation. Houshian and Jing reported on 16 patients
treated with miniexternal fixator spanning the trapeziometacarpal joint (17). Nine of the 16 had a
comminuted pattern. Their fixation was supplemented with percutaneous Kirschner wires to improve
articular alignment. Pain, loss of motion, loss of grip strength, and complications were all reported as
minimal. Their protocol included early motion of all uninjured joints with weekly clinical follow-up. Marsland
et al. also utilized a monolateral external fixator but without any supplemental fixation (18). Again, functional
results were reported as satisfactory with the exception of one case, which required early removal of the
fixator due to pin site infection.
COMPLICATIONS OF BENNETT'S AND ROLANDO'S FRACTURES

Most modern studies report satisfactory outcomes with minimal pain, greater than 90 to 95% return of joint
motion, pinch and grip strength, and low rates of posttraumatic arthritis. Late treatment of Bennett's fracture can
be challenging and is associated with a higher rate of residual stiffness, subluxation, and posttraumatic arthritis.
The step-off can be managed with osteotomy and screw fixation. Mild residual subluxation can be managed with
reduction and pinning. Missed fracture with complete dislocation of the metacarpal carries the chance of
redislocation. It is our preference in this situation to perform ligament reconstruction (Figs. 7-11, 7-12, 7-13, 7-14,
7-15 and 7-16). Most reported complications are
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due to loss of fixation with rates as high as 30% and pin tract infections when percutaneous pinning or external
fixation is used. The rates of posttraumatic arthritis are understandably reported to be higher in Rolando's
fracture than Bennett's fracture. It is important to remember that radiographic arthritis is not indicative of pain or
functional outcome.
FIGURE 7-11 Lateral view of the thumb in a 17-yearold with a missed Bennett's fracture. Note that the thumb
metacarpal base is completely dislocated.
FIGURE 7-12 Immediate post-op ORIF with suture suspension of chronic Bennett's fracture.
FIGURE 7-13 Lateral view 8 weeks' post-ORIF chronic Bennett's injury. Note restoration of the “T sign.”
FIGURE 7-14 AP view of the thumb CMC joint at 8 weeks showing early posttraumatic arthritis.
FIGURE 7-15 Radial abduction of the thumb 8 weeks after ORIF of chronic Bennett's fracture.
FIGURE 7-16 Opposition 8 weeks post-op ORIF chronic Bennett's fracture.
REFERENCES
1. Bennett EH: On fracture of the metacarpal bone of the thumb. Br Med J 2: 12-13, 1886.
2. Rolando S: Fractures of the base of the first metacarpal and a variation that has not yet been described.
Clin Orthop Relat Res 445: 15-18, 2006.
3. Livesley PJ: The conservative management of Bennett's fracture-dislocation: a 26-year follow-up. J Hand
Surg 3B: 291-294, 1990.
4. Ladd AL: The Robert's view: a historical and clinical perspective. Clin Orthop Relat Res 472: 1097-1100,
2014.
5. Dela Rosa TL, Vance MC, Stern PJ: Radiographic optimization of the Eaton classification. J Hand Surg
[Br] 29B: 173-177, 2004.
6. Gedda KO: Studies on Bennett's fracture: anatomy, roentgenology, and therapy. Acta Chir Scand Suppl
193(Suppl): 39, 1954.
7. Cannon SR, Dowd GSE, Williams DH, et al.: A long term study following Bennett's fracture. J Hand Surg
[Br] 11B: 426-431, 1986.
8. Cullen JP, Parentis MA, Chinchilli VM, et al.: Simulated Bennett fracture treated with closed reduction and
percutaneous pinning. J Bone Joint Surg 79A: 413-420, 1997.
9. Edmunds JO: Traumatic dislocations and Instability of the trapeziometacarpal joint of the thumb. Hand Clin
22: 365-392, 2006.
10. Wagner CJ: Methods of treatment of Bennett's fracture-dislocation. Am J Surg 80: 230-231, 1950.
11. Lutz M, Sailer R, Zimmerman M, et al.: Closed reduction transarticular Kirschner wire fixation versus open
reduction internal fixation in the treatment of Bennett's fracture dislocation. J Hand Surg [Br] 28B: 142-147,
2003.
12. Timmenga EJF, Blokhuis TJ, Maas M, et al.: Long-term evaluation of Bennett's fracture: a comparison
between open and closed reduction. J Hand Surg [Br] 19B: 373-377, 1994.
13. Greeven APA, Alta TDW, Scholtens REM, et al.: Closed reduction intermetacarpal Kirschner wire fixation
in the treatment of unstable fractures of the base of the first metacarpal. Injury 43: 246-251, 2012.
14. Leclère FMP, Jenzer A, Hüsler R, et al.: 7 year follow-up after open reduction and internal fixation in
Bennett Fracture. Arch Orthop Trauma Surg 132: 1045-1051, 2012.
15. Van Niekerk JLM, Ouwens R. Fractures of the base of the first metacarpal bone: results of surgical
treatment. Injury 20: 359-362, 1989.
16. Langhoff O, Anderson K, Kjaer-Peterson K: Rolando's fracture. J Hand Surg [Br] 16B: 454-459, 1991.
17. Houshian S, Jing SS. Treatment of Rolando fracture by capsuloligamentotaxis using mini external fixator:
a report of 16 cases. Hand Surg 18: 73-78, 2013.
18. Marsland D, Saghrajka AP, Goldie B. Static monolateral external fixation for the Rolando fracture: a
simple solution for a complex fracture. Ann R Coll Surg Engl 94: 112-115, 2012.
Chapter 8
Surgical Repair: Reconstruction of Acute and Chronic Thumb
Metacarpophalangeal Ulnar Collateral Ligament Deficiency
Thao P. Nguyen
Ngozi Mogekwu Akabudike
INTRODUCTION
The ulnar collateral ligament (UCL) is the primary stabilizer of the thumb metacarpophalangeal (MP) joint under
radial or valgus stress. Injuries to the UCL are common after falls, sporting injuries, or motor vehicle accidents
causing forced abduction or rotation and hyperextension at the thumb MP joint. Campbell, in 1955, coined the
term “gamekeeper's thumb” to describe chronic attritional injury to the UCL seen in Scottish gamekeepers who
killed their game by grasping the head of the animals, often rabbits, between their thumb and index finger to
break the animals' necks (1). Acute injury to the UCL is termed “skier's thumb” because of the high incidence
seen after skiing accidents (2). This occurs when the pole maintains the thumb in an abducted position causing
radial deviation. Incompetence of the thumb UCL frequently leads to painful, chronic instability and poor function.
ANATOMY
The thumb MP joint is a diarthrodial joint capable of abduction, adduction, flexion, and extension. Unlike the
other fingers in the hand, the thumb MP joint must remain stable in both flexion and extension to resist the radial
and ulnar stresses incurred during pinch and grasp. The thumb MP joint has considerable variation in the flexion-
extension arc and degree of valgus laxity (3,4). Stability of the thumb is critical for overall hand function and is
often achieved at the expense of
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motion. Thumb MP joint stability is provided by the bony anatomy as well as dynamic and static restraints.
Compared with the finger metacarpals, the thumb metacarpal head is less spherical and its cartilage is more
limited on the dorsal aspect leading to further stability (5). The static restraints are the proper and accessory
collateral ligaments, the palmar plate, and the dorsal capsule. The proper collateral ligament extends from the
midaxis of the metacarpal head to the palmar aspect of the proximal phalanx (Fig. 8-1). Along with the dorsal
capsule, this ligament is taut in flexion. The proper collateral ligament serves as the primary restraint to valgus
stress with the MP joint flexed and prevents palmar subluxation of the proximal phalanx. The accessory collateral
ligament is palmar to and contiguous with the proper collateral ligament at the metacarpal head and inserts onto
the volar plate (Fig. 8-2). In extension, both the accessory collateral ligament and the volar plate are taut
becoming the principal restraints to valgus stress in this position.
The dynamic stabilizers include the extrinsic (extensor and flexor pollicis longus, extensor pollicis brevis) and
intrinsic (abductor and flexor pollicis brevis, adductor pollicis) tendons and muscles. The adductor mechanism
plays an important role as a dynamic stabilizer. Via its aponeurosis, it
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inserts onto the extensor expansion superficial to the MP joint capsule and UCL (Figs. 8-3 and 8-4). The
adductor also has a deep insertion to the palmar aspect of the proximal phalanx via the ulnar sesamoid bone.
Several structures can be injured after an acute valgus stress to the thumb MP joint. There may be a rupture of
the dorsal capsule, volar plate, adductor mechanism, and extensor pollicis brevis. The thumb will be stable to
valgus stress testing when these structures alone are involved. In contrast, when the proper collateral ligament is
torn, instability will be present when the thumb is stressed in flexion. When the accessory collateral ligament is
also torn, the tear is complete and the MP joint will be unstable in extension and flexion.
FIGURE 8-1 Black arrow points to the proper collateral ligament.
FIGURE 8-2 White arrow points to the accessory collateral ligament.
Thumb UCL ruptures can occur at the midsubstance, proximally or distally. Distal avulsion off the base of the
proximal phalanx is most common and can lead to a Stener lesion. This lesion occurs when the UCL is avulsed
distally from the base of the proximal phalanx and displaces proximal and superficial to the adductor aponeurosis
(6). The adductor aponeurosis becomes interposed between the torn UCL and its insertion at the base of the
proximal phalanx, preventing it from healing in the correct anatomic location. Many feel this is the essential
pathoanatomy determining the need for operative intervention.
FIGURE 8-3 Adductor aponeurosis.

FIGURE 8-4 Forceps lifting adductor aponeurosis.
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Patients will present with persistent pain, swelling, and frequently ecchymosis of the thumb. They complain about
weakness with pinching or gripping activities and may demonstrate frank instability. Physical examination reveals
localized swelling and often radial deviation and palmar subluxation of the proximal phalanx. A lump along the
ulnar aspect of the thumb at the level of the metacarpal head may be palpated, which is highly suggestive of a
Stener lesion. However, lack of a palpable mass does not rule out a Stener lesion (7). After palpation of the joint
and before stability testing, anteroposterior and lateral radiographs are obtained to determine whether an
avulsion fracture is present, typically from the ulnar base of the proximal phalanx. Associated fractures of the
thumb metacarpal may also occur. After careful assessment of the radiographs, evaluation of joint stability with
valgus stress testing is the most critical part of the examination. The goal is to determine whether the injury is
incomplete (grade 1 or 2) or complete (grade 3). Testing stability in full extension and 30 degrees of flexion
places the accessory and proper ligaments under tension, respectively. Carefully align the MP joint before stress
testing because the thumb may already have assumed an angular posture secondary to ligamentous injury, thus
influencing the measurement/severity of instability.
Grade 1 injury is a sprain without joint instability.
Grade 2 injury is an incomplete tear with joint instability but with a firm endpoint on stress testing. A firm
endpoint and less than 30 degrees of valgus laxity rules out a complete UCL tear.
Grade 3 injury is a complete tear with an unstable joint and no endpoint on stress testing. In complete
ruptures, a Stener lesion is more than 80% likely (7).
Instability is defined as opening of the joint more than 30 to 35 degrees without a firm endpoint (or 15
degrees more than the contralateral thumb) at both full extension and 30 degrees of flexion.7 Assessing the
stability in flexion tests the proper collateral ligament, and stressing the joint in extension tests the
accessory collateral ligament and volar plate.
Valgus stress testing should not be avoided for fear of displacing a nondisplaced ligament rupture or avulsion
fracture. The location of the bony fragment does not indicate the ligament location, nor does it indicate joint
stability. Furthermore, if the ligament was not displaced at the time of an uncontrolled injury, controlled stress
testing should not cause the ligament to displace.
Other imaging studies, such as arthrogram, ultrasonography, and magnetic resonance imaging, can provide
further sensitivity and specificity in the diagnosis of UCL tears; however, these are rarely required for accurate
diagnosis.
Grade 1 and 2 UCL injuries are managed conservatively in a splint or thumb spica cast with the interphalangeal
(IP) joint free for immediate range of motion (ROM).
Immobilization of the MP joint is maintained for 3 to 6 weeks (8).
Active and passive ROM can be started either immediately or after immobilization if radial deviation is avoided.
Strengthening, gripping, and pinching activities are initiated at 6 weeks.
Grade 3 or complete injuries, especially if a Stener lesion or joint subluxation is present, should be considered
for surgical repair. Acute injuries can be primarily repaired, whereas chronic injuries may require reconstruction.
The timing of the injury does not always predict the need for reconstruction, and primary repair can often be
performed even months after initial injury. Surgery is also indicated for patients for whom nonoperative treatment
has failed. These patients have persistent pain, decreased pinch and grip strength, difficulties with activities of
daily living (opening jars and turning keys), continued instability, and potentially early arthrosis.
The primary contraindication to repair or reconstruction is MP joint osteoarthritis. Degenerative changes are
most often seen on radiographs but may only become apparent intraoperatively when the joint is explored. If the
articular surfaces are arthritic or have severe chondromalacia, arthrodesis is indicated.
TECHNIQUES
Approach
Make a lazy-S or curvilinear incision centered over the ulnar aspect of the thumb MP joint (Fig. 8-5). Divide the
subcutaneous tissue with dissecting scissors to the level of the extensor expansion and fascia and elevate dorsal
and volar skin flaps. Carefully identify, dissect, and retract the branches of the dorsal sensory branch of the
radial nerve (Fig. 8-6). Identify the oblique transverse fibers of
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the adductor aponeurosis, which may be torn. At this point, inspect for evidence of a Stener lesion and carefully
dissect and protect the torn end of the ligament. Incise the aponeurosis longitudinally, staying parallel and 3 mm
palmar to the extensor pollicis longus tendon (Fig. 8-7). Inspect the dorsal capsule, which may also be torn.
Incise the capsule and inspect the joint for cartilage injuries and/or loose bodies. Perform any debridement as
needed.
FIGURE 8-5 Marked surgical incision.

FIGURE 8-6 Dorsal sensory branch of the radial nerve.
FIGURE 8-7 Adductor aponeurosis incised, forceps holding up the cut edges.
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UCL Repair
If palmar subluxation was seen on preoperative radiographs, the joint should be reduced and pinned before
ligament repair. Pass a smooth 0.045-inch Kirschner wire antegrade through the base of the proximal phalanx
and out through the skin on the radial side of the thumb. Reduce the joint and flex to 15 degrees, and then pass
the wire retrograde across the joint. Fluoroscopy can be used to confirm joint reduction. We only pin the
articulation when managing concomitant joint subluxation; otherwise, we perform repair without the additional
fixation. Next, assess the proper and accessory collateral ligaments for the location of the tear. Most of the time,
the ligaments are torn distally from the base of the proximal phalanx. If there is midsubstance tear, a direct repair
can be carried out with an absorbable 3-0 or 4-0 suture in a figure-of-8 configuration. A small fragment of bone
encountered with the avulsed ligament can be excised. However, larger fragments should be preserved and
ORIF performed with Kirschner wires, screws, or a tension band. Identify the anatomic insertion site of the
ligament at the ulnar aspect of the proximal phalanx. Prepare the site by debriding and curetting the bone.
Mobilize the UCL stump and debride the distal end.
Several techniques have been described to repair the ligament. A suture anchor or transosseus nonabsorbable
suture technique can be used (Fig. 8-8).
Suture anchor technique: Place the anchor in the prepared bony bed. Pass one end of the nonabsorbable
braided suture, such as 3-0 Ethibond, three to four times through the dorsal ligament in a locked running
fashion, then cross transversely, and pass the suture along the volar ligament. Using the other limb of the
suture, which is left free to slide in the anchor, pull the ligament down to the bone. Reduce the joint, and
securely tie the sutures. Alternatively, both limbs of the suture can be placed through the torn ligament as a
horizontal mattress and secured as above.
Transosseus suture technique: Drill two bone tunnels in an ulnar to radial direction at the base of the proximal
phalanx at the prepared bone site. Place a locking suture to grasp the ligament in a similar fashion as
described above with two free suture ends at the distal stump (Fig. 8-9). Pass each free end of the suture
through the bone tunnels, reduce the joint, and directly tie the sutures on the radial side of the bone (Fig. 8-
10). Alternatively, the sutures can be tied over a button.
FIGURE 8-8 UCL repair: nonabsorbable sutures placed in ligament.
FIGURE 8-9 UCL repair: sutures passed through transosseous holes at insertion site at the proximal phalanx
base.
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FIGURE 8-10 UCL repair: sutures tensioned and tied on radial side of proximal phalanx.
Complete the repair by suturing the distal volar portion of the repaired ligament to the volar plate if possible.
Apply gentle radial stress to the joint to test the stability of the repair. Test passive flexion and extension to
ensure maintained smooth motion. Hinging or gapping of the joint with passive motion indicates a repair that is
not anatomically oriented or tensioned appropriately, and the repair should be revised. Suture the dorsal capsule
if there is a large tear. Small tears can be left alone to avoid scarring and decreased flexion. Repair the adductor
aponeurosis with a running absorbable suture, and reconfirm continuity and free gliding of the sensory nerve
branches. Reapproximate the skin with a running subcuticular suture. Place the thumb in a forearm-based spica
cast or splint with the MP joint slightly flexed and the IP joint free.
UCL Reconstruction
With chronic UCL injuries in which the ligament cannot be repaired, reconstruction with a free tendon graft may
be performed. Numerous techniques have been described to reconstruct the UCL. Demonstrated below is the
modified Glickel technique (8,9). A biomechanical comparative study of four reconstructive techniques
demonstrated restoration of stability, but only the Glickel technique most closely approximated normal MP motion
(10). The tendon graft can be secured with anchors, interference screws, or bone tunnels with sutures tied over
a bony bridge. Several graft options are available, but the palmaris longus is the preferred graft. When it is not
available, the plantaris, a toe extensor, a slip of the abductor pollicis longus, or a portion of the flexor carpi
radialis can be used (8,9).
Expose the UCL as described in the “Approach” section above. Excise the proximal and distal stumps of the
UCL. Evaluate the MP joint for articular cartilage damage. If the joint is arthritic, reconstruction is contraindicated
and arthrodesis should be performed. Drill two bone tunnels along the ulnar side of the base of the proximal
phalanx 4 to 5 mm distal to the articular surface. The volar and dorsal bone tunnels should converge at a 45-
degree angle within the medullary canal. The bone tunnel openings should be wide enough so that they will not
crack when the tendon graft is passed through the holes. The tunnels can be connected and enlarged with a
towel clamp and/or curved curette. Pass a heavy suture or flexible wire through the bone tunnels, and clamp
both ends with a hemostat. The suture/wire will be used later to pass the tendon graft. Drill another bone tunnel
at the metacarpal neck exiting radially. This tunnel should be large enough to pass both ends of the tendon graft.
Pass a second heavy suture or flexible wire transversely from the ulnar to radial side of the metacarpal hole, and
clamp the ends with another hemostat. Harvest the free tendon graft. Several graft options are available, but the
ipsilateral palmaris longus is preferred. If unavailable, the plantaris, a toe extensor, a slip of the abductor pollicis
longus, or a portion of the flexor carpi radialis can be used (9). Harvest the palmaris longus tendon with a tendon
stripper or with separate transverse incisions at the proximal wrist crease and midforearm at the
musculotendinous junction. Suture both ends of the free tendon graft with a locked running stitch using
nonabsorbable braided suture. Using a flexible wire or suture at the proximal phalanx, pull one end of the tendon
graft into and through
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the bone tunnels (Fig. 8-11). Be careful not to fracture the bony bridge when pulling traction. Take both limbs of
the tendon graft, and pass them through the metacarpal bone tunnel from the ulnar to radial side (Fig. 8-12). Pull
tension on the graft and test the tension by radially stressing the MP joint in flexion and extension. Ensure that
the joint is concentrically reduced under fluoroscopy. If the joint is not reduced with just manual tensioning of the
graft, a Kirschner wire is used. Bend and cut the wire end superficial to the skin. The Kirschner wire is left in
place for 4 to 6 weeks.
Tie the ends of the graft in a knot at the set tension. Secure the knot to the periosteum with 3-0 braided suture
(Ethibond). An alternative is to place a bone anchor adjacent to the metacarpal tunnel and use the loaded
sutures to secure the knot. If using interference screws, the appropriately sized bone tunnels are created at the
origin of the ligament on the metacarpal head and at the insertion on the proximal phalanx base. The graft is
anchored with an interference screw on the metacarpal first (Fig. 8-13). The other end of the graft is aligned with
the proximal phalanx base, and the appropriate length is marked. The graft is tensioned and then anchored in
the proximal phalanx with a second interference screw with the joint in a reduced position (Figs. 8-14 and 8-15).
Apply gentle radial stress to the joint to test the stability of the repair. Repair the adductor aponeurosis with an
absorbable suture. Reapproximate the skin with a subcuticular running suture. Apply a forearm-based thumb
spica splint or cast, leaving the thumb IP joint free.
FIGURE 8-11 UCL reconstruction: graft passed through the base of the proximal phalanx.
FIGURE 8-12 UCL reconstruction: graft limbs passed through the origin at the metacarpal.
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FIGURE 8-13 UCL reconstruction: graft anchored in metacarpal with interference screw.
FIGURE 8-14 UCL reconstruction: graft anchored in proximal phalanx.
FIGURE 8-15 UCL reconstruction: graft anchored in proximal phalanx.
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PEARLS AND PITFALLS
Care should be taken to avoid excessive traction on the dorsal radial sensory nerve branches.
When making the bone tunnels in the proximal phalanx, drill them wide enough so that the bone bridge does
not fracture when the tendon graft is passed through the holes.
Make sure the joint is in a reduced anatomic position before tensioning and securing the repair or
reconstruction.
Avoid aggressive repair of the dorsal capsule to avoid scarring and stiffness.
The thumb is immobilized in a thumb spica cast for 4 to 6 weeks postoperatively. At that time, the cast and pin if
used are removed and the patient is transitioned to a removable thermoplastic splint. We prefer a hand-based
thumb spica splint with the IP joint free to encourage motion at the remaining joints. The splint is to be worn at all
times except when doing exercises or bathing for 4 weeks. Hand exercises, done under the guidance of a hand
therapist and at home, involve active and gentle activeassisted ROM exercises. After 4 weeks, the splint can be
discontinued except when doing strenuous activities. Patients continue ROM exercises and begin strengthening
exercises with putty and light gripping activities (8). At 12 weeks postoperatively, pinch and grip strengthening
can be initiated. At 4 months after surgery, the patient is permitted full unrestricted activity.
RESULTS
Clinical outcomes for acute primary UCL repair (11):
Significantly better motion with early mobilization.
Full or near full strength (key pinch and grip) was restored in all patients.
Pain relief was significantly improved in all patients.
Clinical outcomes for UCL reconstruction (11):
Greater than 70% of patients had full stability at the MP joint compared with the uninjured side.
Greater than 85% of patients experienced pain relief.
Patients regained greater than 82% of grip and pinch strength compared with the uninjured side.
Patients retained greater than 74% of the ROM at the MP joint.
COMPLICATIONS
Excessive traction on the dorsal radial sensory nerve branches may cause numbness, hyperesthesia, or
dysesthesia on the dorsoulnar aspect of the thumb. This generally tends to resolve over several weeks.
However, more significant injury to the sensory nerve branches can lead to continued pain and even
chronic regional pain syndrome with long-term poor results. Stiffness is a known complication of repair or
reconstruction, and patients need to be appropriately counseled preoperatively. If the reconstruction is
tensioned too tight or aligned incorrectly, patients can develop significant joint stiffness. The MP joint can
develop laxity over time. This can be the result of the graft being placed too loose or increased stress
during aggressive rehabilitation. Careful handling of the soft tissues and appropriate alignment and
tensioning of the ligament repair/reconstruction should lead to long-term gratifying results for the patient and
surgeon.
REFERENCES
1. Campbell C: Gamekeeper's thumb. J Bone Joint Surg Br 37: 148-149, 1955.
2. Gerber C, Senn E, Matter P: Skier's thumb. Surgical treatment of recent injuries to the ulnar collateral
ligament of the thumb's metacarpophalangeal joint. Am J Sports Med 9: 171-177, 1981.
3. Coonrad RW, Goldner JL: A study of the pathological findings and treatment in soft-tissue injury of the
thumb metacarpophalangeal joint. With a clinical study of the normal range of motion in one thousand thumbs
and a study of post mortem findings of ligamentous structures in relation to function. J Bone Joint Surg Am
50: 439-451, 1968.
4. Palmer AK, Louis DS: Assessing ulnar instability of the metacarpophalangeal joint of the thumb. J Hand
Surg 3: 542-546, 1978.
5. Joseph J: Further studies of the metacarpo-phalangeal and interphalangeal joints of the thumb. J Anat 85:
221-229, 1951.
6. Stener B: Displacement of the ruptured ulnar collateral ligament of the metacarpo-phalangeal joint of the
thumb: a clinical and anatomical study. J Bone Joint Surg Br 44: 869-879, 1962.
7. Heyman P, Gelberman RH, Duncan K, et al.: Injuries of the ulnar collateral ligament of the thumb
metacarpophalangeal joint. Biomechanical and prospective clinical studies on the usefulness of valgus stress
testing. Clin Orthop Related Res (292): 165-171, 1993.
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8. Glickel S: Thumb metacarpophalangeal joint ulnar collateral ligament reconstruction using a tendon graft.
Tech Hand Up Extrem Surg 6: 133-139, 2002.
9. Glickel SZ, Malerich M, Pearce SM, et al.: Ligament replacement for chronic instability of the ulnar
collateral ligament of the metacarpophalangeal joint of the thumb. J Hand Surg 18: 930-941, 1993.
10. Lee S, Kubiak E, Lawler E, et al.: Thumb metacarpophalangeal ulnar collateral ligament injuries: a
biomechanical simulation study of four static reconstructions. J Hand Surg 30: 1056-1060, 2005.
11. Samora J, Harris J, Griesser M, et al.: Outcomes after injury to the thumb ulnar collateral ligament—a
systematic review. Clin J Sport Med 23: 247-254, 2013.
Chapter 9
Operative Management of PIP Dislocations and Fracture-
Dislocations
Nikhil R. Oak
Brian Najarian
Jeffrey N. Lawton
BACKGROUND
Proximal interphalangeal (PIP) joint fracture-dislocations are intra-articular injuries that also include a
concomitant soft-tissue injury to the surrounding ligamentous and capsular structures. These injuries most often
occur from an axial load, but a bending torsional load or combined mechanism of injury can also occur. Injuries to
the PIP joint are among the most common in the hand (1). Evaluation and treatment may be delayed as the injury
can often be dismissed as a “jammed finger” (2). Swelling, stiffness, arthritis, and permanent pain can be the
result of inadequate treatment of these injuries (3).
The head of the proximal phalanx is bicondylar and has almost complete articular congruency with the middle
phalanx allowing for joint stability with axial loading (4). The PIP joint is crucial in our ability to grasp objects,
contributing 85% of the total active motion necessary due to its unique anatomy with 110 degrees arc of motion
(5,6). Stability in the flexion-extension arc is provided by the thick volar plate, proper and accessory collateral
ligaments, checkrein ligaments, and joint capsule, which form a three-sided box with the dorsal aspect relatively
devoid of stabilizing structures (6) (Fig. 9-1). The extensor complex plays a role in limiting volarly directed
stresses. The precise anatomy of the joint allows for equal loading throughout motion; therefore, any subluxation
or abnormalities in the joint can cause increased wear and arthritis (7).
CLASSIFICATION
The pattern of joint injury depends on the direction, degree, and rate of force application. Injuries to the middle
phalanx can be classified based on the portion of the articular surface involved and the direction of deformity
(Fig. 9-2).
Palmar lip fractures with dorsal subluxation or dislocations of the middle phalanx are the most common type of
injury. These injuries are caused by axial loading and hyperextension of the middle phalanx on the head of the
proximal phalanx. Palmar lip fractures can be graded based on the percentage of articular surface involvement
and joint subluxation (7,8,9). Stable fractures are those that remain reduced in extension with less than 30% of
articular surface involvement. Tenuously stable fracture-dislocations are those that involve 30% to 50% of the
articular surface with reduction of the
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joint maintained with less than 30 degrees of flexion. Unstable fractures are those with greater than 50% of the
articular surface involved or 30% to 50% involved but needing more than 30 degrees of flexion to maintain
adequate reduction of the PIP joint (Fig. 9-3).
Dorsal lip fractures occur with palmar subluxation of the middle phalanx and can be caused by axial loading with
hyperextension or an avulsion fracture by hyperflexion (10). Stable injuries are
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those in which the joint remains reduced in extension. Unstable injuries are those demonstrating palmar
subluxation of the middle phalanx with the joint in extension. Often, a disruption of the normal digital cascade
accompanies palmar subluxations or dislocations.
FIGURE 9-1 PIP joint anatomy. The thick volar plate, proper and accessory collateral ligaments, checkrein
ligaments, and joint capsule form a three-sided box.
FIGURE 9-2 PIP fracture-dislocation general classifications. A: Volar. B: Dorsal. C: Pilon.
FIGURE 9-3 A: Fracture-dislocation. B: Volar bone loss that can lead to instability.
FIGURE 9-4 Classification of unicondylar proximal phalangeal fractures.
Pilon fractures of the middle phalanx are those where the volar and dorsal margins are disrupted with
comminution of the central articular surface (10,11). These fractures are caused by high-energy axial load with
the joint in partial flexion and are almost always unstable. Commonly, dorsal and palmar fragments surround a
depressed central fragment.
The proximal phalanx can also be involved in PIP fractures-dislocations. These injuries occur during an axial
load through the tip of the finger. Proximal phalanx articular fracture patterns include unicondylar, bicondylar, or
comminuted fractures. Unicondylar fractures can be classified into four basic groups: oblique volar, long sagittal,
dorsal coronal, and volar coronal (12) (Fig. 9-4).
INDICATIONS
It is important to promptly recognize the complexity of the initial injury and to understand appropriate
treatment options. Most PIP dislocations and fracture-dislocations can be treated with closed reduction,
splinting, early motion, and close follow-up. Open treatment of PIP joint dislocations or fracture-dislocations
is indicated when the joint cannot be concentrically reduced or if the reduction cannot be maintained by
closed methods. Open reduction is also indicated in open displaced fractures and most unstable fractures
that present after a remote trauma. Unstable or tenuous fractures include those that require more than 30
degrees of flexion to maintain reduction. Attempting closed management of a fracture-dislocation that would
require extreme flexion to prevent redislocation will likely result in a significant flexion contracture. Other
indications for open reduction include significant articular depression, displacement, or joint incongruity. An
irreducible joint is consistent with entrapment of a soft-tissue structure such as the volar plate, collateral
ligament, and/or tendons in the joint, which necessitate surgical extraction prior to reduction. There are no
absolute contraindications to surgical treatment of these injuries other than a medically unstable patient or
inability of the patient to cooperate with operative treatment and postoperative rehabilitation.
The goals of treating PIP joint fracture-dislocations include obtaining concentric joint reduction, restoring a
stable arc of motion, and allowing early motion to minimize adhesions and contractures (11). If full stable
extension is achieved, recovery is much simpler as regaining/correcting PIP joint extension is far more
difficult than regaining/correcting flexion. Anatomic restoration is desirable but not as important as the above
outlined goals (10,13).
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Presentation and Evaluation
After injury, the PIP joint quickly stiffens. Pain and instability will limit motion in the acute period following injury.
Subacute or chronic injuries will present with stiffness, loss of function, persistent swelling, and pain due to the
fibrosis of the capsular and ligamentous structures of the joint.
An adequate history must be obtained, which includes a detailed description of the mechanism of injury and any
previous treatments. The neurovascular exam is generally normal; however, capillary refill and sensation should
be documented. Skin and soft tissues should be inspected particularly at the level of the PIP flexion crease for
any open or healed wounds that would indicate an open fracture-dislocation. Deformity noted in extension or
flexion can indicate a volar or dorsal dislocation. Location and extent of swelling or tenderness can indicate
which soft-tissue structures are injured. Attention should be paid to both axial and rotational alignments, which
may be altered secondary to articular depression of a condyle. This can be recognized clinically as angulation
when full digital flexion and extension is attempted. Passive and active range of motion should also be
documented, including any deficits. A digital nerve block may be necessary for a thorough exam (5). Passive
testing of joint stability can allow for the assessment of volar plate and collateral ligament integrity; subluxation
during active range of motion suggests ligament disruption or a significant intra-articular fracture (1). It is
important to note the range of motion through which the joint remains reduced. For dorsal dislocations, the
degree of extension that results in instability or dislocation determines the angle for extension block splinting or
pinning.
Elson's test (14) can be performed to evaluate the integrity of the central slip of the extensor apparatus. From a
90-degree flexed position of the PIP joint, the patient can be asked to actively extend the PIP against resistance.
If the central slip is still intact, the force will be demonstrated through the middle phalanx and the distal
interphalangeal (DIP) joint will remain supple during this effort. If the DIP joint remains rigidly extended due to the
compensatory extensor actions of the lateral bands alone, a complete rupture of the central slip can be
documented. In an acute setting, the patient may need a local digital block to allow for a good effort.
Diagnostic Studies
After clinical examination, radiographic views including posteroanterior (PA), lateral, and oblique views of the
digit are required. Oblique views are helpful in identifying fracture planes and to judge the extent of fracture
comminution. Radiographs can be misleading as a seemingly small fragment of bone may result in incompetence
of structures that lead to joint instability. A postreduction true lateral is needed to determine the amount of
articular involvement, and views in full PIP joint extension are used to evaluate the stability of the joint. With
superimposition of the proximal phalangeal condyles, subtle subluxation of the middle phalanx can be detected.
Dorsal subluxation of the joint produces the “V” sign caused by separation of the incongruous articular surface of
the proximal phalanx head and undamaged portion of the middle phalanx base. Presence of the “V” sign
indicates subtle joint instability (11) (Fig. 9-5). Dynamic fluoroscopy, when available, can also be very helpful in
evaluating joint reduction and stability.
FIGURE 9-5 A: Lateral radiograph of an unstable PIP fracture-dislocation. Greater than 50% articular surface
involvement with dorsal dislocation. B: The “V sign” dorsally that demonstrates an incompletely reduced PIP
fracture.
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Palmar Lip Fractures Stable fractures maintain joint congruency in full PIP extension, tenuous fractures stay
reduced with less than 30 degrees of flexion, and unstable fractures need more than 30 degrees of flexion to
maintain joint congruency (4,5,10,11).
Dorsal Lip Fractures Stability is assessed in full extension. Articular surface involvement is usually less than
50% when stable, but if there is any palmar subluxation in full extension or concern for central slip rupture, these
fractures are deemed unstable (5,10).
Pilon Fractures All pilon fractures are grossly unstable and involve up to 100% of the articular surface. They
often have areas of central depression and peripheral comminution and have the greatest amount of joint
disruption (4).
Condylar Fractures Fractures of the head of the proximal phalanx also undergo the same workup as middle
phalangeal base fractures. PA radiographs are beneficial to visualize articular step-off. Type I fractures have an
oblique volar fracture pattern, which renders it highly unstable. These fractures can create both lateral
angulation and rotational misalignment. Type II fractures have a long oblique fracture line in the sagittal plane,
which also renders it unstable. Type III fractures have a dorsal coronal fragment, which is usually small and can
be associated with a dorsal PIP joint dislocation. Type III fractures are often stable and can be treated with
fragment excision unless the fracture involves greater than 50% of the condylar diameter in the PA plane. Type
IV fractures have a palmar coronal fragment and can be associated with a volar PIP joint dislocation. These
fragments are unstable and can interfere with flexion.
TECHNIQUES
Closed Reduction
Most PIP joint dislocations and fractures can be treated with closed reduction. This is almost always
successful for acute dorsal PIP dislocations. Volar dislocations can be more problematic especially if there is a
rotatory component to the deformity.
Reductions can be performed immediately after injury or if in a delayed presentation with the help of a 1%
lidocaine digital block.
Complete a neurologic exam of the digit prior to block and confirm adequate anesthesia before the reduction
maneuver.
Dorsal dislocations—apply gentle traction on the finger with the wrist in neutral position followed by a volar
directed force on the base of the middle phalanx while holding the proximal phalanx steady.
Volar dislocations
Without rotatory component—place wrist in neutral position and apply gentle longitudinal traction with a
dorsally directed force to the middle phalanx and a volarly directed force on the proximal phalanx.
With rotatory component—often more difficult to reduce as the head of the proximal phalanx becomes
entrapped between the central slip and one of the lateral bands of the extensor mechanism. Attempt
reduction by placing the metacarpophalangeal (MCP) and PIP joints in 90 degrees of flexion with wrist
extension and apply light traction to the digit while rotating the middle phalanx in the direction opposite to
the deformity.
Open Reduction: Positioning/Equipment

Patient is placed supine with a radiolucent hand table.
Brachial or forearm tourniquet can be placed prior to draping—can be inflated to 250 mm Hg after
exsanguinating the arm prior to incision.
Surgery can be performed under general or regional anesthesia. Axillary blocks can achieve adequate
sensory anesthesia and motor relaxation of muscle groups.
Supinate the operative hand. Optionally, it can be held in place with a “lead hand” malleable positioner.
Mini C-arm fluoroscopy is utilized to assess and confirm fracture/joint reduction.
Depending on the technique used—minifragment plate/screw set, 24-gauge cerclage wire, and/or Kirschner
(K)-wires should be available.
Closed Reduction and Percutaneous Pinning

When acute fractures are reducible by closed means and an anatomic reduction can be achieved, this can be
maintained by percutaneous K-wire fixation.
Fractures involving the articular surface can be compressed together by using a fracture reduction forceps
externally.
Mini C-arm is used to assess fracture reduction with a goal being an anatomic joint surface and congruent PIP
joint.
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Reduction is then secured using percutaneous K-wires—a minimum of 2 is required to prevent
redisplacement.
Either 0.045- or 0.035-inch K-wires can be used based on the size of the fracture and the phalanx.
Optimal fixation points in the proximal phalanx are distal and palmar as the central and dorsal regions have
thin cortical elements and provide weaker fixation.
For condylar fractures (9):
K-wires are inserted from the contralateral dorsal side of the intact condyle and advanced palmarly into the
fractured condyle. Holding the PIP joint in extension relaxes the conjoined lateral bands.
K-wires may also be inserted from the palmar/lateral fractured fragment and advanced to the intact condyle.
For palmar lip fractures (8,15):
A towel clip can be used to reduce the volar fragment with one point placed percutaneously into the
middorsal base of the middle phalanx and other point percutaneously through the midline of the flexor
tendons directly onto the volar fragment.
The K-wire is manually inserted through the skin just lateral to the volar limb of the towel clip distal to the
articular surface.
The K-wire can then be drilled across the dorsal cortex of the middle phalanx and through the dorsal skin.
This is then repeated on the other side of the volar lip so that two wires are now entering the volar fragment
and exiting dorsally through the skin.
The K-wires can be withdrawn from the dorsal side until almost flush with the volar fracture fragment.
PIP joint alignment can be then be maintained with transarticular or extension block pinning.
Obtain definitive PA, lateral, oblique images and place in dressing/digital splint.
Surgical Approaches
Surgical approaches are chosen based on fracture pattern and the direction of instability. It is important to be
familiar with several different surgical approaches including the volar (Bruner), dorsal (Chamay or Swanson), and
midaxial approaches to the PIP joint. If the main fracture line or comminution pattern is dorsal, a dorsal or
midaxial approach can be used. When the fracture is primarily volar, such as with palmar lip fracture-dislocations
or pilon-type fractures, then a volar approach is chosen.
Volar Approach (Bruner) (16,17) (Fig. 9-6)

Incision is made on the palmar surface in a zigzag fashion from the MCP joint crease across the PIP joint to
the DIP joint flexion crease. In a larger digit, two limbs of the Bruner incision may be necessary per
segment.
A thick subcutaneous ulnar-based flap is mobilized at the level of the flexor sheath.
Digital neurovascular structures are mobilized next to the flexor sheath—this helps in avoiding traction on
these structures as the joint is displaced during the exposure and surgical fixation.
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Underlying flexor tendons are exposed by either of the following:
Incising flexor sheath over the PIP joint on three sides to create a rectangular flap between the A2 and A4
pulleys.
Alternatively, the flexor sheath can be split longitudinally to expose the tendons.
Both the flexor digitorum profundus and superficialis tendons can be retracted to the side to expose the
volar plate—Penrose drain or silicone vascular vessel loops can be employed to retract the tendons.
The PIP joint is exposed by dividing the volar plate transversely and just proximal to the distal insertion; this
allows retraction of this proximally as a proximally based flap.
The collateral ligaments are sharply incised or elevated to access more dorsal fracture fragments and to aid
in joint reduction.
For a more comprehensive exposure, a “shotgun” approach (18,19) can be used.
The PIP joint is hyperextended after releasing the collateral ligaments from their origin and maintains
alignment on its own accord at approximately 130 degrees of hyperextension.
Assess the neurovascular bundles during this maneuver to ensure they subluxate dorsally and do not
sustain a traction injury.
Dorsal Approach (Chamay) (20) (Fig. 9-7)

A dorsal longitudinal skin incision is made proximally along the midline and curving distally around the
dorsal aspect of the PIP joint to expose the extensor mechanism.
A distally based flap of the central slip can be made in a V shape with the pedicle extending as far as the
proximal third of the proximal phalanx.
This flap can be reflected distally, and the intact lateral bands can subluxate volarly and laterally to provide
adequate exposure of the PIP joint.
After surgical fixation, the flap can be repaired with 4-0 nonabsorbable sutures and allows early active
motion within the first few days.
Alternatively, the central slip can be incised longitudinally (Swanson).
Midaxial Approach (Fig. 9-8)
After marking the interphalangeal joint axes of rotation, identify the midaxial line between these points.
The skin incision on this midaxial line will be 2 mm dorsal to the digital nerve and artery.
Avoid an ulnar-sided incision on the small finger and radial-sided incision on the index finger as these
surfaces are important for surface contact.
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Identify Cleland's ligament with fibers running volar to dorsal and thin fascial layers around the digital nerve
and artery.
Divide Cleland's ligament and deep to the neurovascular bundle.
The bundle should remain in the volar flap.

Expose the lateral portion of the middle phalanx and lateral margin of the flexor sheath.
PIP joint can be entered between the volar plate and accessory collateral ligament to inspect the joint for
further surgical fixation.
Conversely, for proximal phalanx fractures, the midaxial approach can be slightly modified (Fig. 9-9).
After a standard midaxial incision, the transverse retinacular ligament can be incised.
The conjoined lateral bands and extensor tendon can be retracted dorsally.
This allows a dorsal capsulotomy to expose the articular surface of the PIP joint.
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Closure and Splinting
Volar plate and central slip flaps can be closed with 4-0 nonabsorbable suture.
Flexor tendon sheath is closed with 5-0 or 6-0 suture—can be either absorbable or nonabsorbable.
After tourniquet is deflated, bipolar cautery is used to achieve hemostasis.
Skin is closed with interrupted 5-0 nylon or nonabsorbable suture.
The patient is then placed into an intrinsic plus volar-based splint with MCP joints flexed 70 to 90 degrees
and IP joints extended based on postfracture reduction stability.
FIGURE 9-6 A: Bruner approach—palmar zigzag skin incision. B: Two limbs may be needed between flexion
creases of large digits. C: After flexor sheath is exposed—it can be incised on three sides between the A2 and
A4 pulleys and retracted laterally. D: Flexor digitorum superficialis and profundus tendons are exposed. E: PIP
joint is distracted while flexor tendons are retracted laterally. F: Joint is gently hyperextended until it maintains
this “shotgun” alignment.
FIGURE 9-7 Dorsal approach (Chamay). A: Incision midline with curves laterally along PIP and DIP joints. B: A
distally based V-shaped flap of central slip is created and pulled distally to expose the PIP joint.
FIGURE 9-8 A: Midaxial (blue line) and midlateral (red line) approaches. Midaxial line can be approximated by
flexing finger and marking points at the IP joints where flexion creases end dorsally. B: Cross-sectional diagram
of these approaches. Midaxial approach is dorsal to the neurovascular bundle and midlateral is approximately at
the level of the bundle.
FIGURE 9-9 A: Dorsoradial approach. B: Release transverse retinacular ligament. Probe is below the
transverse retinacular ligament. C: Dorsally retract conjoined lateral band and central tendon to expose capsule.
D: Capsulotomy allows for intra-articular fracture exposure. E: Fracture can be anatomically positioned and held
by bone reduction forceps.
Dynamic or Static External Fixation (See Chapter 10: “External Fixation of Hand Fractures and
Dislocations” for Additional Details)
The use of traction via either static or dynamic external fixation employs the concept of ligamentotaxis to maintain
general joint reduction (21,22). Agee (23,24) employed a force couple device using K-wires to lever the middle
phalanx base and the head of the proximal phalanx to maintain joint reduction through the motion arc. Schenck
(25) described another method of traction by using a pin placed transversely through the middle phalanx and
attached to an external ring in order to distract the joint and allow adequate range of motion (26). Travelling
traction or dynamic external fixation as described by Hastings and Ernst (27) employed a bent K-wire through the
axis of rotation and the middle phalanx to provide longitudinal traction while permitting passive/active ROM. With
traction techniques, it is important to have an intact dorsal cortex to prevent the PIP joint from subluxating.
Numerous studies have demonstrated good outcomes by accepting incomplete articular reduction and instituting
early motion as long as the PIP joint remains congruous (13,24,26).
Extension Block Pinning (4,28,29)

When reduction of unstable PIP joint fracture-dislocations is difficult to maintain using extension block splinting
alone, extension block pinning with K-wires can be employed. Compared to standard immobilization or
transarticular K-wire placement, there is a lower risk of permanent joint contracture because early active motion
is encouraged.
The PIP joint is flexed to 90 degrees.
K-wire insertion point is confirmed with fluoroscopy.
The K-wire is inserted in retrograde fashion down the shaft of the proximal phalanx approximately 30 degrees
off the long axis under fluoroscopic guidance (Fig. 9-10).
Joint reduction is confirmed and range of motion visualized under fluoroscopy.
A 60-degree arc of motion is ideal.

The blocking pin allows active motion but blocks extension beyond the point that joint subluxation occurs.
Gently stress the PIP joint in extension under fluoroscopy to troubleshoot for potential instability.
Postoperative care: Early active motion is encouraged.
Active/passive PIP flexion can be undertaken immediately.
Active PIP extension is allowed to the degree afforded by the blocking pin.
K-wire is removed at 4 to 6 weeks.
FIGURE 9-10 K-wire is inserted 30 degrees off the long axis under fluoroscopic guidance.
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Minifragment Fixation (17,30-32) (Fig. 9-11)
Lag screw fixation provides more rigid stability and allows for earlier range of motion. This type of fixation is
indicated in larger fracture fragments with less comminution. Intraoperatively, it is not uncommon to discover that
these fracture fragments are more comminuted than radiographs demonstrate and using screw fixation may
further fragment the bone.
The joint and fracture is exposed using an appropriate exposure technique described previously.
Soft tissues are cleared from the fracture site with a dental pick or Freer elevator.
It is important to maintain cancellous and subchondral bone on the articular fragments; bone grafting may be
required to prevent articular collapse.
Dorsal radius autograft or allograft can be used into the metaphysis directly or through a cortical window.
After anatomic reduction of the fracture, fragments can be preliminarily stabilized with bone reduction forceps
or K-wires.
Choose appropriate-sized screws based on fragment size—usually 1.0 to 1.7 mm.
Drill the screw hole perpendicular to the fracture line and measure depth using the depth gauge.
If fragment size permits, overdrill the near cortex equal to the screw's outer diameter in order to perform
interfragmentary lag fixation.
Use a self-tapping, minifragment cortical screw for fixation.
Headless screws or countersinking the screw can be helpful in avoiding tendon and soft-tissue irritation.
While screws are self-tapping, the use of a tap prevents stripping of screws and a more gentle handling of
the fragments.
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In larger fragments, two screws or a screw with supplemental threaded K-wire can be used for rotational
stability.
For condylar fractures of the proximal phalanx, a similar technique is used (Fig. 9-12).
The screw can be placed safely near the proximal origin of the collateral ligament.
For more distal screws, the collateral ligament can be partially elevated subperiosteally from proximal to
distal or a smaller screw can be placed just distal to the origin with the PIP joint in flexion.
Following definitive fixation, put the digit through full ROM under mini C-arm fluoroscopy to ensure stable
concentric reduction.
If the joint does not remain concentrically reduced, fixation can be augmented with extension block pinning,
transarticular K-wire (8,33), or dynamic external fixation (27).
Postoperative care: Thermoplastic splint provides protected motion.
Progressive active and active-assisted ROM begins post-op days 2 to 5 based on comfort.
Close follow-up for 3 weeks to monitor for loss of reduction.
Motion restrictions are removed at 5 to 6 weeks; continue therapy for 1 to 2 months after splint removal for
continued ROM.
FIGURE 9-11 A-C: Preoperative AP, lateral, oblique radiographs of small finger PIP joint demonstrating large
dorsal/ulnar fragment. D: Dorsal approach to PIP joint with fracture exposed. E: 1.7-mm screw placed to achieve
stable fixation of the fragment. Screw head has been countersunk. F,G: AP and lateral postoperative
radiographs.
FIGURE 9-12 A: Drilling across fracture. B: Measuring depth to judge screw size needed. C: Overdrilling
fracture fragment for lag fixation. D: AP diagram of screw position for fracture fixation. E: Lateral diagram of
screw position. F: Intraoperative view after screw fixation.
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Cerclage Wiring (19) (Fig. 9-13)
This technique allows for reduction and fixation of multiple smaller articular fragments while also providing for
early range-of-motion exercises. This technique requires the more thorough “shotgun” exposure so there is an
increased risk of fibrosis and stiffness postoperatively.
Volar incision is employed with a “shotgun” exposure of the PIP joint.

Mobilize the neurovascular bundles and release the distal volar plate with a rim of tissue to allow repair.
Carefully elevate most proximal portion of the central slip leaving the distal portion intact and clear a thin ring
of periosteum around the bony fragments of the middle phalanx.
Wire loop can thus be tightened directly against the bone allowing for firm fixation of the fracture fragments.
The funnel-shaped base of the middle phalanx aides in fixation and prevents postoperative slippage with
early ROM.
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Use a 24-gauge steel wire to make a loop twisted on itself and fashion it so that it is slightly larger than the
base of the middle phalanx.
Reduce the fracture and seat the wire loop around the base. Gently tighten the wire loop using a tonsil to
allow for circumferential compression of the fracture fragments.
Be aware of central depression and joint subluxation after confirming articular reduction.
Cut the twisted free end of the loop and seat the end on the volar or volar lateral surface of the middle phalanx
base flush to the cortex.
This wire will be covered by the repaired volar plate to prevent mechanical irritation of the flexor tendons.
If necessary, supplementary K-wire fixation may be used to allow for further fixation prior to final tightening of
the cerclage wire.
Postoperative care is very similar to the above listed care after minifragment fixation.
Focus on aggressive early active range of motion.
FIGURE 9-13 Cerclage wire fixation. A: Preoperative lateral radiograph showing pilon-type pattern. B: Volar
“shotgun” exposure shows volar fragment with central articular depression. C: View after reduction and cerclage
wire fixation allowing circumferential compression. D: Postoperative radiograph conforming reduction of central
articular fragment.
Volar Plate Arthroplasty (4,18,34-36) (Fig. 9-14)

Volar plate arthroplasty has been described as an option when the articular surface in dorsal fracture-dislocation
cannot be restored. Some authors use this technique to salvage chronic fracture-dislocations, while others prefer
this for many acute injuries with bone loss and comminution. This method advances the volar plate into the
middle phalangeal fracture defect to restore stability and resurface the joint articulation.
Volar Bruner incision and “shotgun” approach is used to enter the joint.
Volar plate is detached from the middle phalanx and from the radial/ulnar margins, keeping as much tissue as
possible.
Both collateral ligaments should be elevated or released to allow for joint hyperextension.
In chronic cases, sharp release of checkrein ligaments may be necessary for advancement of the volar
plate. It is important to leave the central portion intact for blood supply.
Dorsal capsulotomy may be required for full range of passive motion in chronic cases.
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After hyperextension to provide a “shotgun” view, small fracture fragments are debrided.
Create a transverse trough on the middle phalanx at the junction of the joint surface and fracture defect with a
small rongeur or osteotome.
Depth of trough should be equal to the thickness of the volar plate.

Proximal ulnar and radial margins of volar plate flap are secured with 3-0 nonabsorbable suture placed in
locking fashion.
Two straight Keith needles are passed through each side of the trough created earlier with a wire driver
aiming central and distally to penetrate through the cortex and central slip.
Sutures are pulled through bone tunnels using the needles as the PIP joint is flexed.
Mini C-arm fluoroscopy is used to ensure reduction of the PIP joint.
If ROM is limited, you may need to advance the volar plate flap more distally by releasing checkrein
ligaments or step cutting lengthening the ligaments.
Sutures can be tied over a button dorsally or directly to the dorsal periosteum (below).
Make a dorsal skin incision with a no. 11 blade with needles in place prior to pulling suture through—this
prevents inadvertent cutting of the suture. After a small incision distal to the insertion of the central slip, at
the triangular aponeurosis, the sutures are then tensioned down to the periosteum.
A transarticular K-wire can be used to protect the reconstruction postoperatively but prohibits early motion.
Some authors have advocated using dynamic distraction and external fixation to protect the reconstruction and
allow early motion postoperatively (8,10,21).
Alternatively, extension block pinning may aid in postoperative therapy.
Post-op care:
Transarticular K-wire can be removed in 2 to 3 weeks.
Continue extension block splitting up to 6 weeks.
If a suture button is used, this can be removed at 6 weeks and then work on ROM.
FIGURE 9-14 A: Incision for volar plate arthroplasty. B: Approach for volar plate arthroplasty and VP mobilized—
in forceps. Note N/V bundles mobilized and windows on both the radial and ulnar aspects of the flexor tendons.
C: Insertion of volar plate by using a locking stitch passed into trough through holes drilled with Keith needles
and then tied over dorsal middle phalangeal periosteum/central slip insertion.
Hemihamate Autografting (37-41)

Hamate osteochondral autografting is a technique to re-establish the palmar base of the middle phalanx in dorsal
fracture-dislocations when fracture comminution does not allow for restoration of the joint and traction is unable
to maintain joint stability. Proposed by Hastings (39), the contour of the palmar articular surface of the middle
phalanx can be reproduced by using the anatomically similar contour of the hamate articulation with the 4th and
5th metacarpal bases. Some authors propose that this is the treatment of choice for fractures involving 50% of
the volar articular surface that is not amenable to primary internal fixation (37).
Volar Bruner incision with “shotgun” exposure is used as described previously.
Abnormal area or fracture fragments on palmar joint surface are identified and removed after measurements
made with calipers. The height of the defect is determined by measuring the impacted fragments (Fig. 9-15A).
A rongeur or saw can be used to create a smooth surface at the volar and distal margins of the base.
Alternatively, bone wax can be used to model the defect and aid in contouring the hamate graft.
Hamate autograft harvest.
A 3-cm transverse incision is made just proximal to the carpometacarpal joint at the bases of the ring and
small fingers. Fluoroscopy is used to confirm accurate placement of the incision (Fig. 9-15B).
Dorsal capsulotomy is made to visualize the hamate. Graft dimensions are marked using the distal articular
ridge as a reference.
Axial and sagittal cuts can be made with a small saw blade or osteotome with care taken to prevent
damaging the articular surface.
A proximal trough is created to allow the coronal plane cut to be placed appropriately.
The graft should be slightly larger than measured to allow for contouring (Fig. 9-15C).
The graft is then given final contours and placed into the defect at the base of the middle phalanx that was
debrided earlier.
Graft is provisionally stabilized with a K-wire followed by definitive fixation with two 1.0- or 1.5-mm screws in a
volar to dorsal direction (Fig. 9-15D).
The PIP joint is then reduced and assessed fluoroscopically to confirm correct screw length, graft positioning,
and range of motion (Fig. 9-15E, F).
The articular surface of the hamate is thicker than the middle phalanx, so a radiologic stepoff may be seen
when no articular step-off between the graft and phalangeal base is actually present.
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The volar plate is reattached to the collateral ligaments along the lateral margins of the middle phalanx, and
the reflected flexor sheath can be interposed.
Post-op course: bulky dressing and dorsal splint applied with PIP held in 20 degrees of flexion.
Begin limited ROM within a week from surgery with figure-of-eight splint and a 15-degree extension block
for a period of 6 weeks prior to ramping up activities as tolerated.
FIGURE 9-15 A: Volar “shotgun” exposure of joint demonstrating depressed and malunited volar fragment. B:
Incision for hamate autograft—fluoroscopy used to confirm site. C: Hamate autograft. D: Graft fixed with two 1.5-
mm screws in a volar to dorsal direction. E,F: AP and lateral radiographs demonstrating fixation and reduction.
PEARLS AND PITFALLS

PIP joint dislocations and fracture-dislocations can often be missed and thought of as a “jammed finger.”
Avoid forceful passive testing for stability, which can convert a partial ligamentous injury to a complete tear.
Preserve the A2 and A4 pulleys to avoid bowstringing of the flexor tendons in the “shotgun” approach.
If fracture fragments are too small or comminuted, screw fixation may further worsen bone loss and fixation
may be inadequate.
Screw or K-wire fixation in the middle phalanx base should be angled distally to maximize length and
purchase.
Minimize the number of passes when drilling with K-wires or with screws as this may result in further fracture
fragmentation.
Always check fluoroscopic images postreduction and take PIP joint through arc of motion to ensure adequate
stability.
Lateral images are important to ensure implant does not violate the extensor mechanism or remain too
prominent causing soft-tissue irritation.
Bony defects should be filled with bone graft to prevent subsidence and recurrent subluxation.
COMPLICATIONS
Posttraumatic arthritis
PIP joint stiffness, flexion contracture, and extensor lag
Persistent PIP joint subluxation or dislocation
Loss of fracture fixation or worsening displacement
Deep infection or pin site infection
Numbness/paresthesias
Vascular injury
Malunion or nonunion
Boutonniere deformity
Chronic pain
RESULTS
Fifteen patients treated with various ORIF techniques including K-wire, tension band, and screw fixation
—the average post-op ROM was 17 to 90 degrees (9).
Grant (31) reported on 14 patients after miniscrew or plate fixation who had an average total PIP ROM of
100 degrees, while Cheah (42) noted average PIP motion of 75 degrees in 13 patients.
Stern (13) discussed results after pilon fractures of the PIP joint treated with splinting, traction or open
reduction, and K-wire fixation. They found at 25-month follow-up that skeletal traction had fewer
complications and comparable outcomes when compared to open reduction with average ROM of 80
degrees versus 70 degrees (open).
Weiss (19) described 12 patients treated with cerclage fixation. At an average of 2.1-year follow-up,
11/12 patients demonstrated no degenerative changes, average total arc of motion was 89 degrees
without implant failure, and all patients treated had pain-free motion.
Malerich (18,34) discussed 17 cases of volar plate arthroplasty; only 3 patients reported mild pain, and
an average of 95 degrees of PIP motion was restored. Radiographs showed marked remodeling of the
disrupted surface. However, 6 to 12 degrees of flexion contracture resulted. They found a higher chance
of redislocation if greater than 50% of the middle phalangeal base is involved.
Calfee et al. (37) studied 33 patients treated with hemihamate arthroplasty. All patients healed and
maintained joint reduction. Average PIP arc was 71 degrees for acute fractures and 69 degrees in
chronic injury reconstructions. They concluded it was a good treatment choice for fractures involving
greater than 50% of the articular surface that is not amenable to primary internal fixation.
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Salter (43) reviewed the effect of motion on articular cartilage and found that cartilage undergoes
deterioration if motion is limited and that the articular surface remodels over time.
Numerous studies and clinical reports support the theory that anatomic surface restoration is
unnecessary if subluxation is corrected and motion is instituted shortly after injury (22,23,30,43).
REFERENCES
1. Chinchalkar SJ, Gan BS: Management of proximal interphalangeal joint fractures and dislocations. J Hand
Ther 16(2): 117-128, 2003.
2. Williams CS IV: Proximal interphalangeal joint fracture dislocations: stable and unstable. Hand Clin 28(3):
409-416, xi, 2012.
3. Kiefhaber TR, Stern PJ: Fracture dislocations of the proximal interphalangeal joint. J Hand Surg Am 23(3):
368-380, 1998.
4. Blazar PE, Steinberg DR: Fractures of the proximal interphalangeal joint. J Am Acad Orthop Surg 8(6):
383-390, 2000.
5. Freiberg A, Pollard BA, Macdonald MR, et al.: Management of proximal interphalangeal joint injuries. Hand
Clin 22(3): 235-242, 2006.
6. Leibovic SJ, Bowers WH: Anatomy of the proximal interphalangeal joint. Hand Clin 10(2): 169-178, 1994.
7. Schenck RR: Classification of fractures and dislocations of the proximal interphalangeal joint. Hand Clin
10(2): 179-185, 1994.
8. Elfar J, Mann T: Fracture-dislocations of the proximal interphalangeal joint. J Am Acad Orthop Surg 21(2):
88-98, 2013.
9. Hastings H II, Carroll C IV: Treatment of closed articular fractures of the metacarpophalangeal and
proximal interphalangeal joints. Hand Clin 4(3): 503-527, 1988.
10. Kang R, Stern PJ: Fracture dislocations of the proximal interphalangeal joint. J Am Soc Surg Hand 2(2):
47-59, 2002.
11. Calfee RP, Sommerkamp TG: Fracture-dislocation about the finger joints. J Hand Surg Am 34(6): 1140-
1147, 2009.
12. Weiss AP, Hastings H II: Distal unicondylar fractures of the proximal phalanx. J Hand Surg Am 18(4):
594-599, 1993.
13. Stern PJ, Roman RJ, Kiefhaber TR, et al.: Pilon fractures of the proximal interphalangeal joint. J Hand
Surg Am 16(5): 844-850, 1991.
14. Elson RA: Rupture of the central slip of the extensor hood of the finger. A test for early diagnosis. J Bone
Joint Surg Br 68(2): 229-231, 1986.
15. Vitale MA, White NJ, Strauch RJ: A percutaneous technique to treat unstable dorsal fracture-dislocations
of the proximal interphalangeal joint. J Hand Surg Am 36(9): 1453-1459, 2011.
16. Bruner JM: Surgical exposure of the flexor pollicis longus tendon. HAND 7(3): 241-245, 1975.
17. Green A, Smith J, Redding M, et al.: Acute open reduction and rigid internal fixation of proximal
interphalangeal joint fracture dislocation. J Hand Surg Am 17(3): 512-517, 1992.
18. Eaton RG, Malerich MM: Volar plate arthroplasty of the proximal interphalangeal joint: a review of ten
years' experience. J Hand Surg Am 5(3): 260-268, 1980.
19. Weiss AP: Cerclage fixation for fracture dislocation of the proximal interphalangeal joint. Clin Orthop
Relat Res (327): 21-28, June 1996.
20. Chamay A: A distally based dorsal and triangular tendinous flap for direct access to the proximal
interphalangeal joint. Ann Chir Main 7(2): 179-183, 1988.
21. Krakauer JD, Stern PJ: Hinged device for fractures involving the proximal interphalangeal joint. Clin
Orthop Relat Res (327): 29-37, June 1996.
22. Morgan JP, Gordon DA, Klug MS, et al.: Dynamic digital traction for unstable comminuted intra-articular
fracturedislocations of the proximal interphalangeal joint. J Hand Surg Am 20(4): 565-573, 1995.
23. Agee JM: Unstable fracture dislocations of the proximal interphalangeal joint of the fingers: a preliminary
report of a new treatment technique. J Hand Surg Am 3(4): 386-389, 1978.
24. Agee JM: Dynamic traction and early passive movement for fractures of the proximal interphalangeal
joint. Clin Orthop Relat Res (214): 101-112, Jan 1987.
25. Schenck RR: Dynamic traction and early passive movement for fractures of the proximal interphalangeal
26. Finsen V: Suzuki's pins and rubber traction for fractures of the base of the middle phalanx. J Plast Surg
Hand Surg 44: 209-213, 2010.
27. Hastings H II, Ernst JM: Dynamic external fixation for fractures of the proximal interphalangeal joint. Hand
Clin 9(4): 659-674, 1993.
28. Viegas SF: Extension block pinning for proximal interphalangeal joint fracture dislocations: preliminary
report of a new technique. J Hand Surg Am 17(5): 896-901, 1992.
29. Maalla R, Youssef M, Ben Jdidia G, et al.: Extension-block pinning for fracture-dislocation of the proximal
interphalangeal joint. Orthop Traumatol Surg Res 98(5): 559-563, 2012.
30. Hamilton SC, Stern PJ, Fassler PR, et al.: Mini-screw fixation for the treatment of proximal
interphalangeal joint dorsal fracture-dislocations. J Hand Surg Am 31(8): 1349-1354, 2006.
31. Grant I, Berger AC, Tham SK: Internal fixation of unstable fracture dislocations of the proximal
interphalangeal joint. J Hand Surg Br 30(5): 492-498, 2005.
32. Freeland AE, Benoist LA: Open reduction and internal fixation method for fractures at the proximal
interphalangeal joint. Hand Clin 10(2): 239-250, 1994.
33. Deitch MA, Kiefhaber TR, Comisar BR, et al.: Dorsal fracture dislocations of the proximal interphalangeal
joint: surgical complications and long-term results. J Hand Surg Am 24(5): 914-923, 1999.
34. Malerich MM, Eaton RG: The volar plate reconstruction for fracture-dislocation of the proximal
interphalangeal joint. Hand Clin 10(2): 251-260, 1994.
35. Dionysian E, Eaton RG: The long-term outcome of volar plate arthroplasty of the proximal interphalangeal
36. Blazar PE, Robbe R, Lawton JN: Treatment of dorsal fracture/dislocations of the proximal interphalangeal
joint by volar plate arthroplasty. Tech Hand Up Extrem Surg 5(3): 148-152, 2001.
37. Calfee RP, Kiefhaber TR, Sommerkamp TG, et al.: Hemi-hamate arthroplasty provides functional
reconstruction of acute and chronic proximal interphalangeal fracture-dislocations. J Hand Surg Am 34(7):
1232-1241, 2009.
38. Capo JT, Hastings H II, Choung E, et al.: Hemicondylar hamate replacement arthroplasty for proximal
interphalangeal joint fracture dislocations: an assessment of graft suitability. J Hand Surg Am 33(5): 733-739,
2008.
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39. Hastings HCJ, Steinberg B, Stern P: Hemicondylar hamate replacement arthroplasty for proximal
interphalangeal joint fracture/dislocations (abstr). Presented at the 54th Annual Meeting of the American
Society for Surgery of the Hand, Boston, MA, 1999.
40. Williams RM, Hastings H II, Kiefhaber TR: PIP fracture/dislocation treatment technique: use of a hemi-
hamate resurfacing arthroplasty. Tech Hand Up Extrem Surg 6(4): 185-192, 2002.
41. Williams RM, Kiefhaber TR, Sommerkamp TG, et al.: Treatment of unstable dorsal proximal
interphalangeal fracture/dislocations using a hemi-hamate autograft. J Hand Surg Am 28(5): 856-865, 2003.
42. Cheah AE, Tan DM, Chong AK, et al.: Volar plating for unstable proximal interphalangeal joint dorsal
fracture-dislocations. J Hand Surg Am 37(1): 28-33, 2012.
43. Salter RB: The physiologic basis of continuous passive motion for articular cartilage healing and
regeneration. Hand Clin 10(2): 211-219, 1994.
Chapter 10
External Fixation in the Hand
William H. Seitz Jr
INTRODUCTION
Miniaturization of external fixation apparatus, applications, and techniques has evolved to afford hand surgeons
a unique and useful tool to treat a variety of difficult conditions that they face on a regular basis. Principles as
applied to the hand are similar to those applied across segments of the entire limb and long bones; however, the
complexities of the hand including tendon gliding, multiple small joint interactions, fine neurologic structures, and
limited space for skeletal targeting all require technical expertise and careful planning and execution of the
process. The techniques of applying miniature external fixation in the hand have application in acute trauma, in
posttrauma reconstruction and staged management of infections, in burn reconstruction, in deformity correction,
and in congenital hand surgery (1,2,3,4,5,6,7,8,9,10).
This chapter will review the indications, contraindications, perioperative preparation, surgical technique, “pearls
and pitfalls,” postoperative management, potential complications, and their management with an overview of
expected results.
INDICATIONS
Acute trauma
Unstable intra-articular fractures (CMC, MP, PIP joints)
Unstable segmental fractures (pathologies unknown)
Open fractures (gunshot wounds)
Crush injuries
Soft-tissue loss
Posttrauma reconstruction
Malunion/nonunion
Arthritis
Instability
Contracture
Deformity
Amputation
Burn reconstruction
Contracture
Deformity
Amputation
Congenital hand deformity
Symbrachydactyly
Transverse terminal arrest
Hypoplastic thumb
Complex syndactyly (Apert's syndrome)
Radial clubhand
Contractures
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Acute Trauma
In the setting of acute trauma, indications for external fixation can include unstable intra-articular fractures
involving the proximal interphalangeal (PIP), metacarpophalangeal (MP), and carpometacarpal (CMC) joints
(Fig. 10-1; Video 10-1). They may also include unstable segmental fractures with or without bone loss, open
fractures, crush injuries, or injuries with soft-tissue loss (skin, tendon, and muscle injury) (Fig. 10-2; Video
10-2). Some contaminated wounds may present
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indications for external fixation to be used as a spanning apparatus until definitive internal fixation can be
performed pending wound care, debridement, and resolution of potential infection (Fig. 10-3; Video 10-3).
Areas of traumatic or burn loss of skin and subcutaneous tissue can be bridged and position maintained
pending adequate coverage (Fig. 10-4; Video 10-4). Combinations of joint, tendon, burn, and soft-tissue
injury may also be managed by means of dynamic fixation, which allows some degree of tendon excursion
avoiding adhesions and contractures during the early healing phases (Fig. 10-5; Video 10-5) (4,11).
FIGURE 10-1 Miniaturized external fixation can provide a wide area of application throughout the hand.
This includes stabilization of fractures and dislocations across the CMC joints (A,B). Applications across
fractures and dislocations of the MP joint (C,D) and across the PIP joint (E,F) where fractures and/or
fracture dislocations may be well stabilized by a combination of external fixation and limited internal fixation.
FIGURE 10-2 Open fractures with comminution and surrounding soft-tissue injury (A-D), gunshot wounds
with bone loss (E,F), and in certain cases of tumor with pathologic fracture requiring grafting and spanning
stabilization (G-J).
FIGURE 10-3 In the face of severe open trauma with loss of soft tissue and bone and potential
contamination/infection, a complex external fixation system can be designed to allow for debridement, soft
tissue revascularization, and allow access for wound care to allow secondary reconstruction once the
environment has been declared viable.
External fixation utilizes the principles of “ligamentotaxis” whereby the soft-tissue envelope is tensioned
around the skeletal architecture to both mold the fragments into place and provide tension on the tendinous,
muscular, and ligamentous structures providing a physiologic environment
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so as to minimize contracture and adhesions. The principle, however, does not ensure fine fragment
realignment in the face of intra-articular fractures and therefore may need to be augmented by means of fine
fragment realignment using various forms of internal fixation, intercalary support, or subchondral support in
the face of loss of bone stock through bone grafting (Fig. 10-6; Video 10-6) (5,8,9,10).
FIGURE 10-4 In the face of severe burns with loss of substance (A-C), soft-tissue coverage is obtained
when external fixation can be used to both stretch contracted soft tissues and perform callotasis lengthening
of the remaining skeletal parts (D-F) and ultimately functional digital prehension (G-I).
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Posttraumatic Reconstruction
The outcome of trauma may result in malunion or nonunion, posttraumatic arthritis, joint instability,
contracture, or amputation.
Indications for use of external fixation in posttraumatic reconstruction include providing stable fixation for
realignment and osteotomy; compression arthrodesis, which leaves no long-term hardware in place;
transarticular stabilization in conjunction with ligament reconstruction; slow distraction of severe
contractures; and distraction lengthening of an amputated thumb or multiple digits (11,12,13,14,15,16)
(Figs. 10-7A and 10-8; Videos 10-7 and 10-8).
FIGURE 10-5 Custom additions to external fixation include hinges, which can be centered over the center of
rotation of a joint as seen clinically (A-C), and in postoperative video showing dynamic excursion of an MP
joint, which has been reconstructed due to severe capsular and ulnar collateral ligament rupture.
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FIGURE 10-6 Periarticular fractures frequently require fine fragment approximation using augmentation
techniques with K-wires, screw fixation, and bone grafting (A-E). Successful management of these
periarticular fractures provides an excellent functional outcome (F,G).
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FIGURE 10-7 External fixation can also be used to control rotational and angular realignment in conjunction
with osteotomy of deformity such as seen in this child having undergone prior complex syndactyly release
who has significant functional malalignment of the central two fingers (A). A planned rotational angular
correction can be seen based on the alignment of the fixator pins inserted before osteotomy and following
realignment (B). Similar correction is performed in the shortened and deformed ring finger (C). Final
alignment with restoration of normal cascade is seen in (D) and (E). Once the fixator is aligned,
compression can be achieved across the fixator to enhance healing of the osteotomy, much as it can in an
arthrodesis. (F) through (K) demonstrate surgical technique of exposure, denuding the articular surfaces,
and compression arthrodesis of a thumb MP joint with good early function during the healing phase (L).
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FIGURE 10-8 Distraction lengthening can provide both stabilization and creation of elongated functional
length digits once soft-tissue coverage has been achieved (A-D). During the process of distraction
lengthening and consolidation of the new bone that is forming in the distraction gap functional hand use is
learned, guided by our hand therapists (E-H).
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In all these cases, the external fixation apparatus acts as a stable bridge or self-limited traction system,
which is quite sturdy and supports the complexities of multiple joint control through the interaction of
extrinsic and intrinsic musculotendinous excursion across the injured area allowing joint mobility of adjacent
articulations and ligamentous flexibility. It is indicated in conditions where other alternative forms of fixation
may not provide ideal stability (K-wires, interfragmentary screws, plate and screw fixation, and
intramedullary fixation).
Burn and Congenital Hand Reconstruction
In patients who are born with congenital hand differences, such as symbrachydactyly, transverse terminal
arrest, hypoplastic thumbs, or complex syndactyly with failure of formation of parts, external fixation
techniques can be utilized applying the techniques of callotasis or distraction lengthening to elongate small
digital remnants to form functional digits for purposes of sensate prehension (Fig. 10-9; Video 10-9)
(12,16,17,18,19,20,22,23,24). It may also be utilized for angular and rotational deformity correction and
syndactyly releases or for soft-tissue stretching and distraction following burns or in cases of severe radial
clubhand about the deformed, contracted wrist in preparation for centralization or radialization procedures
(Fig. 10-10; Videos 10-10A through 10E) (25).
FIGURE 10-9 Use of external fixation for distraction lengthening can be used to provide functional length
following toe phalanx transfer in areas of hypoplasia and construction of a functional, sensate, prehensile
hand as in this young child with severe symbrachydactyly and hypoplastic thumb who has undergone
multiple toe phalangeal transfer of the index metacarpal and distraction lengthening resulting in a
functioning prehensile hand (A-L).
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FIGURE 10-10 A child with severely hypoplastic (3B) thumb (A) has undergone two toe phalanx transfers
followed by distraction lengthening (A-C). During the lengthening process, the child learns to use the
reconstructed thumb (D).
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FIGURE 10-10 (Continued) Six years later after fine plasty and transfer of the flexor digitorum superficialis
of the ring finger to FPO and extensor indicis proprius to EPO, the patient demonstrates a very functional
stable thumb (E-H).
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FIGURE 10-10 (Continued) The video and multiple images are seen of young children following toe
phalangeal transfers and distraction lengthening of multiple digits. The children demonstrate just how
dexterous they can be even when substantial skeletal architecture is missing from the beginning. Severe
radial clubhand in a neonate can be managed with slow distraction and centralization (I,J) providing early
realignment of the hand and wrist on the forearm with ability to perform functional activities at a young age.
CONTRAINDICATIONS
Contraindications to the use of external fixation of the hand include conditions of gross infection, poor bone
stock, or a suspected noncompliant patient who will not be able to participate in the needed degree of self-care
following surgery (1,2,3,4,11).
It is extremely important for the surgeon to undertake careful discussions with the patient and/or patient's family
regarding the need for postoperative compliance, including pin site care, active participation in a rehabilitation
program, and avoidance of secondary injury or contamination. If this is not possible, external fixation should not
be utilized.
Contraindications
Infection
Poor bone stock
Noncompliant patient or family
Careful patient selection and education regarding patient participation in pin site care and a rehab program, the
importance of hygiene, and avoidance of contamination are all paramount as a first step in preoperative
preparation of the patient.
The surgeon should carefully review x-rays and any other appropriate imagining studies to ensure a complete
understanding of the skeletal and soft-tissue environment through which the external fixation apparatus will be
applied. In addition, plans for appropriate wound closure, soft-tissue coverage, tendon repair and excursion, as
well as need for fine fragment augmentation with internal fixation (K-wires, interfragmentary screws, suture
anchors) need to be planned out carefully preoperatively so all needed instrumentation is available at the time of
surgery. A surgical approach through safe planes should be designed to allow easy access to intact structurally
sound segments of bone for fixator pin insertion and external frame assembly, which will not interfere with
surrounding hand function (1,2,3,11).
A system should be utilized that affords flexibility in predrilling, insertion of secure self-tapping threaded half pins,
and multiple options in frame configuration, while allowing radiographic access to the area of reconstruction
(1,2,3,8,9,11).
Based on the pathology at hand, a surgeon should also plan for the duration of fixation, when device removal is
anticipated; how to optimize the rehabilitation program; and whether secondary surgical procedures may be
needed so that the patient can be adequately prepared for the journey ahead.
Preoperative Planning
Careful patient selection.
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Patient education/preparation.
X-ray/imaging study review.
Understand soft-tissue environment.
Plan for additional internal fixation/bone graft.
Know the anatomy and “safe planes.”
Choose a flexible/user-friendly system.
Have mini-image fluoroscopy readily available.
SURGICAL TECHNIQUE
External fixation of the hand requires a good knowledge of anatomy, especially the anatomy of the extensor
mechanisms of the hand and fingers. In almost all cases, the plan of approach for insertion of the external fixator
pins will fall between the dorsal and lateral planes. Rarely will the plane of insertion be a direct central dorsal or
central lateral plane, but rather an in-between (dorsal lateral) plane. The safest approach is through a limited
open incision (26). This allows visualization of adjacent tendon structures, providing ability to retract them and/or
create a small longitudinal split in them to ensure excursion of the extensor tendon during the healing process. It
also permits visualization of intrinsic muscles to avoid injury and ensures central pin insertion to avoid damage to
the small bones of the hand by means of avoiding creation of scarring and open-section defects. Predrilling
provides a pilot hole for the insertion of self-tapping threaded half pins centrally located in the bone. This
minimizes heat generation and therefore potential for bone necrosis, pin loosening, and infection (27).
Pins should be inserted in a plane that minimizes obstruction or movement of adjacent fingers.
In intra-articular comminuted fractures, external fixation can be combined with fine fragment control by
augmenting with limited internal fixation (fine K-wires or minifragment screws). The fine fragment fixation allows
precise restoration of articular congruity, while the spanning external fixator provides overall alignment and
rotational and angular control and stability (4,11). This allows adjacent joint motion and tendon glide. Relaxing
incisions can be made in the extensor mechanism overlying the proximal or middle phalanges, the tendon can be
retracted, and after predrilling and pin placement, tendon glide and adjacent joint motion should be checked prior
to closure. Once the fixator pins are in place, the surgeon can opt to perform fine fragment fixation, insert bone
graft as needed for subchondral support, and then assemble and secure the entire fixator construct after first
closing the incision with sutures. Nonabsorbable sutures are recommended in adults, while absorbable plain gut
sutures are advisable in children. Proximally in the metacarpals or carpal bones, a small longitudinal incision can
allow for visualization and retraction and ensure central placement of the fixator pins through a very limited
incision. Again, closure before assembly of the entire construct adds to the ease of the procedure (Video 10-11A-
P).
When the device is to be used for compression arthrodesis, pins should be placed on either side of the joint to
be compressed, the joint surface prepared (either cup and cone or creation of two opposed flat surfaces with
preplanned angular cuts), and the joint surfaces opposed and provisionally held with a central K-wire. Predrilling
and insertion of fixator pins and closure of the incision are then performed, and the longitudinal rod is fixed to the
fixator pins through connecting pin terminals. Once aligned longitudinally at the proper orientation to prevent
angulation in the medial lateral plane with the desired amount of flexion built in, compression can be achieved
across the arthrodesis site by means of clamp compression along the long axis of the connecting fixator bar.
Some mini-fixator systems, such as Stryker's MicroFix (Stryker, Mahwah, NJ), offer radiolucent, very strong
carbon fiber connecting rods of various lengths, which ensure full visualization during assembly with the
fluoroscope and postoperatively for standard radiographs. This technique also allows secondary compression if
needed at the first postoperative visit by loosening and recompressing (28).
Once the final compression across the arthrodesed joint is performed (whether this is performed intraoperatively
or postoperatively), the central guiding K-wire is removed.
In cases of stabilization during ligament repair or reconstruction (gamekeeper's thumb), ligamentotaxis can be
achieved to provide appropriate tension on the healing capsule and ligaments to avoid postoperative contracture
and allow early joint mobilization when the soft tissues have fully healed. In some cases, centrally placed hinge
mechanisms may afford the ability to allow the injured joint to go through a limited arc of motion during the
healing process (Video 10-12) (11).
A combination of ligamentotaxis across the healing joint combined with outrigger fixation and support of adjacent
segments can provide dynamic excursion of adjacent repaired tendons. This requires creative adaptation of
extensions to the external fixator in conjunction with “creative hand therapists” (Fig. 10-11; Video 10-13A,B)
(6,11,29).
In patients with burn contractures and for distraction for creation of functional length segments in patients
following traumatic amputation and in children with congenital hand differences, various forms of slow distraction
have been employed to gradually open contracted areas and functionally lengthen bone remnants in conjunction
with syndactyly release, and in some cases following prior transplantation of bone after it has revascularized
(Fig. 10-12; Video 10-14) (4,11,25,30,31).
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External fixation pins can be used as alignment guides in cases of malunion when 3-dimensional corrective
osteotomy is to be performed (32).
FIGURE 10-11 A comminuted intra-articular osteochondral fracture of the metacarpal heads of the midline ring
fingers is seen following high-speed trauma (A). The extensor tendons have been ruptured and there is some
degree of local skin loss (B). The osteochondral fragments are too small to hold with rigid fixation and have been
sutured back into place with absorbable sutures. Following extensor tendon repair and grafting from adjacent
fingers and wound closure with rotation flaps, the MP joints are held with gentle ligamentotaxis using spanning
fixators to traverse the metacarpal phalangeal joints. Outrigger extensions have been fabricated by our hand
therapists with dynamic extensor slings to rule out tendon excursion through PIP and DIP motion (C-F). The
patient can be seen exercising with the device 6 weeks postoperatively when the external fixator is removed. His
subsequent motion is near full as seen at 3 months postoperatively.
FIGURE 10-12 In severely hypoplastic hands where there is only a remnant of thumb and digits, web space
creation and development of a reasonably functional thumb post and digits, which have sensation, and
prehension can be developed with transplantation of an index metacarpal remnant to the thumb position creating
a widened first web space, transplantation of toe phalanges, and secondary distraction lengthening to create a
functional prehensile hand (A-L).
PEARLS AND PITFALLS

Pearls
Visualize the bone where fixator pins are to be inserted (small longitudinal incisions).
Identify overlying extensor tendon and retract or locally split to ensure tendon gliding and movement of
adjacent joints.
Predrill the bone (ensures central placement and avoids further injury from soft tapping pins).
Check depth of fixator pin with mini-image fluoroscopy (avoid overinsertion of pins, but make sure there is
full thread purchase in both cortices).
Use self-tapping threaded half pins of appropriate length to ensure adequate extension outside the skin for
application of connectors and for access for wound and pin site care. Allow 1 week in a soft dressing for
swelling and initial postoperative discomfort to resolve.
Commence active finger mobility within the soft dressing immediately.
Allow 1 week of rest between surgery and commencement of distraction lengthening.
Once distraction has begun, it should be performed slowly (0.25 mm increments four times a day). We
recommend the lengthening to be performed at breakfast, lunch, dinner, and bedtime.
When a dynamic fixator (adoptive hinges and dynamic outrigger elastic supports) are utilized, such dynamization
should be initiated when it is felt the primary site of injury is stable enough to allow it (usually 1 to 3 weeks).
Pitfalls
Avoid percutaneous pin insertion.

Tendon “skewering” and tethering. This prevents adjacent joint mobility and tendon excursion, which
results in pain and contracture.
Avoid eccentric drilling and placement of pins, which can cause weakening and fracture through creation
of open-section defects resulting in loss of fixation.
Avoid inadequate fixation, which result in loosening, increased swelling, and infection.
Avoid self-drilling self-tapping pins (these have a tendency to burn the bone; the nonfluted cutting trocar has
no threads and requires deeper placement to gain thread purchase on the far
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cortex resulting in potential injury to important soft-tissue structures and tendon nerve artery) on the far side
of the bone.
Avoid through-and-through fixation (this tends to interfere with adjacent digit excursion).
Avoid assembling the device prior to wound closure (adds technical difficulty to the procedure).
When fine fragment approximation is needed, don't hesitate to add limited internal fixation as needed. Don't
expect the external fixator to provide such fine fragment realignment.
Do not use this technique in a noncompliant patient (careful patient assessment and education are
mandatory). Employing this technique in a noncompliant patient can result in disastrous complications
despite meticulous surgical technique.
A bulky soft dressing should be used for the 1st week to provide support and limit posttraumatic/postoperative
swelling. However, it is recommended that the therapist educate the patient preoperatively and on the day of
surgery involving the importance of engagement in the rehabilitation program. Gentle movement of the adjacent
joints and overlying tendons from day 1 is extremely important. At 1 week postoperatively, the soft dressing is
removed, and the patient is instructed regarding adjacent joint mobility and tendon excursion exercises and in pin
site care (in the case of children, parents are instructed in pin site care).
Pin site care includes twice daily cleansing with a sterile Q-tip and hydrogen peroxide to break up crusts of blood
and serum, which form along the fixator pin at the site of entry. This is continued for 1 to 2 weeks. We have
found that more than twice a day cleansing can create hypertrophic granulation tissue and irritation and less than
twice a day allows the buildup of subcutaneous serum, which can then result in the local pin tract infection. After
1 to 2 weeks of twice a day cleaning with peroxide, when the skin is fully healed and closed around the fixator
pins and there is minimal serum formation, the cleansing can be changed to twice a day with rubbing alcohol in
place of the peroxide. This provides a very clean and dry entry site. At this point, sutures are removed and the
absorbable sutures have dissolved in children. We now allow patients to get the fixator wet with clean running
water (no immersion) in the shower once a day and followed immediately by one of the alcohol cleanings (Fig.
10-13; Video 10-15A,B) (11,24,25).
FIGURE 10-13 The key part of the postoperative rehabilitation is active range of motion as seen in this woman
who has had excision of a tumor and intercalary bone grafting. Twice a day diligent pin site care first with
hydrogen peroxide and then with alcohol after 2 weeks remain a key part of the patient's responsibility (A-C).
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Regular therapist visits are recommended to ensure progression of mobility of the adjacent joints and stability of
the area of repair/reconstruction. In cases of distraction lengthening, weekly return visits to the surgeon are
accompanied with weekly radiographs to ensure the proper progression. After desired functional length has been
achieved, a period of consolidation is required for new bone to form a distraction gap. This usually requires two
times the duration of distraction in children and three times the distraction in adults. Radiographic assessment of
new bone filling distraction gap and formation of new cortical bone on at least 3 sides suggests adequate
structural integrity to allow removal of the external fixator/distractor (23,24,25).
Removal of the device is performed in the clinic setting in adults, while most children under the age of 12 will
require brief general anesthesia for comfort and compliance during removal. In some cases, after fixator removal,
temporary splinting may be added to provide additional support to the healing structures while continuing to allow
adjacent joint mobility.
Key points in postoperative management

Soft-tissue dressing 1 week.
Pre-op and immediate post-op commencement of instruction and education and adjacent joint mobility and
tendon glide.
At 1 week, begin pin site care with dilute peroxide two times daily.
2 to 3 weeks post-op, advance to two times daily cleaning with rubbing alcohol.
Once a day showering will be allowed at 2 to 3 weeks.
Office removal of external fixator in adults.
4 to 6 weeks trauma to allow bone healing.

6 to 8 weeks tendon or ligament healing.
Consolidation (minimum two to three times duration of lengthening) when callotasis distraction is
employed.
Regular hand therapy follow-up.
Careful communication between therapist and surgeon.
COMPLICATIONS
The most common complication of external fixation is local pin tract infections. These begin with some
redness and local drainage. In the vast majority of cases, they can be managed with the use of a course or
oral antibiotics and enhanced local pin site care. Other complications include contracture, stiffness, fracture
around pin site, loosening and failure of the external fixation construct, nonunion of the
fracture/arthrodesis/new bone regenerate, and deep infection (12,24,25).
The likelihood of these complications occurring is greatly minimized by following the guidelines outlined in
the pearls and pitfalls section.
RESULTS
The use of ligamentotaxis to provide gentle physiologic transarticular soft-tissue tension allows restoration
of functional mobility across injured joints. Use of the external fixator to provide stability during soft-tissue
healing allows adjacent joints to remain mobile and overlying tendons to maintain their gliding capacity and
avoid adhesions and contractures. Fracture and bone healing can occur physiologically in a stable
environment due to the structural soundness of the external fixation construct. Restoration of functional
length of digits and restoration of functional web space, especially between the thumb and index, is readily
achieved through the technique of distraction lengthening.
Restoration of function is the key element to using this technique in both children and adults (Fig. 10-14;
Video 10-16) (11,22,23,24,25,30,31).
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FIGURE 10-14 Posttraumatic stabilization of fracture dislocations similarly is treated with the stability of an
external fixator and allows early excursion of the surrounding tendons and intrinsic muscles, which then
achieve functional outcome following removal (A-D).
REFERENCES
1. Seitz WH Jr, Gomez W, Putnman MD, et al.: Management of severe hand trauma with a mini external
fixateur. Orthopedics 10: 601-610, 1987.
2. Putnam MD, Seitz WH: Advances in fracture management in the hand and distal radius. Hand Clin 5: 455-
470, 1989.
3. Alexander VA, Seitz WH Jr: Current trends and uses of external fixation in the hand and carpus. Curr Opin
Orthop 8(IV): 1-6, 1997.
4. Seitz WH Jr, Froimson AI, Leb R, et al.: Augmented external fixation of unstable distal radius fractures. J
Hand Surg 16A: 1010-1016, 1991.
5. Hochberg J, Ardenghy M: Stabilization of hand phalangeal fractures by external fixator. W V Med J 90: 54-
57, 1994.
6. Patel MR, Joshi BB: Distraction method for chronic dorsal dislocation of the proximal interphalangeal joint.
Hand Clin 10: 327-337, 1994.
7. Buchler U: The small AO external fixator in hand surgery. Injury 25(Suppl 4): D55-D63, 1994.
8. Asche G: Possibilities for stabilization of an intraarticular comminuted fracture of the first metacarpal: use
of the external mini fixator. Handchir Mikrochir Plast Chir 13(3-4): 247-249, 1981.
9. Riggs SH Jr, Cooney WP III: External fixation of complex hand and wrist fractures. J Traumatol 23(4): 332-
336, 1983.
10. Bilos ZJ, Eskestrand T: External fixation in comminuted gunshot fractures of the proximal phalanx. J Hand
Surg [Am] 4(4): 357-359, 1979.
11. Goldberg SH, Seitz WH Jr: Management of complications following metacarpal and phalangeal fractures
and dislocations. In: Seitz WH Jr, ed. Fractures and dislocations of the hand and fingers. Chicago, IL:
American Society for Surgery of the Hand, 2013. [e-book].
12. Seitz WH Jr, Froimson AI: Callotasis lengthening in the upper extremity. Indications, techniques and
pitfalls. J Hand Surg [Am] 16A: 932, 1991.
13. Matev IB: Thumb reconstruction through metacarpal bone lengthening. J Hand Surg [Am] 5: 482, 1980.
14. Matev IB: First metacarpal lengthening for thumb reconstruction. Orthop Travmatol Protez 6: 11, 1969.
15. Kessler J, Baruch A: Experience with distraction lengthening of digital rays in congenital anomalies. J
Hand Surg [Am] 2: 394, 1977.
16. Seitz WH Jr, Dobyns JH: Digital lengthening with emphasis on distraction osteogenesis in the upper limb.
Hand Clin 9: 699-706, 1993.
17. Seitz WH Jr, Froimson AI: Digital lengthening using the callotasis technique. Orthopedics 18: 129-138,
1995.
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18. Heitman C, Levin LS: Distraction lengthening of thumb metacarpal. J Hand Surg 29B: 71-75, 2004.
19. Toh S, Narita S, Arai K, et al.: Distraction lengthening by callotasis in the hand. J Bone Joint Surg 84B:
205-210, 2002.
20. Houshian S, Ipsen T: Metacarpal and phalangeal lengthening by callus distraction. J Hand Surg 27B: 13-
26, 2002.
21. Ogino T, Kato H, Ishii S, et al.: Digital lengthening in congenital hand deformities. J Hand Surg [Am] 19B:
20-129, 1994.
22. Seitz WH Jr, Bley L: Distraction lengthening in the hand using the principle of callotasis. In: Raskin KB,
ed. Atlas of the hand clinics. Philadelphia, PA: WB Saunders, 2000: 31-39.
23. Miyawaki T, Masuzawa G, Hirakawa M, et al.: Bone lengthening for symbrachydactyly of the hand with
the technique of callus distraction. J Bone Joint Surg 84A: 986-991, 2002.
24. Seitz WH Jr, Shimko P, Patterson RW: Long term results of callus distraction lengthening in the hand and
upper extremity for traumatic and congenital deficiencies. J Bone Joint Surg Am 92(Suppl 2): 47-58, 2010.
25. Seitz WH Jr: Distraction lengthening in the hand and upper extremity. In: Green DP, ed. Operative hand
surgery. 6th ed. New York, NY: Churchill Livingstone, 2010: 1483-1502.
26. Seitz WH Jr, Putnam MD, Dick HM: Limited open surgical approach for external fixation of distal radius
fractures. J Hand Surg 15A: 288-293, 1990.
27. Seitz WH Jr, Froimson AI, Brooks DB, et al.: External fixator pin insertion techniques: biomechanical
analysis and clinical relevance. J Hand Surg [Am] 16(3): 560-563, 1991.
28. Seitz WH Jr, Sellman DC, Scarcella JB, et al.: Compression arthrodesis of the small joints of the hand.
Clin Orthop Relat Res (304): 116-121, 1994.
29. Alison DM: Fractures of the base of the middle phalanx treated by a dynamic external fixation device. J
Hand Surg [Am] 21B: 305-310, 1996.
30. Netscher DT, Lewis EV: Technique of nonvascularized toe phalangeal transfer and distraction
lengthening in the treatment of multiple digit symbrachydactyly. Tech Hand Up Extrem Surg 12: 114-120,
2008.
31. Patterson RW, Seitz WH Jr: Nonvascularized toe phalangeal transfer and distraction lengthening for
symbrachydactyly. J Hand Surg [Am] 35(4): 652-658, 2010.
32. Seitz WH, Froimson AI: Management of malunited fractures of the metacarpal and phalangeal shafts.
Hand Clin 4: 529-536, 1988.
Chapter 11
Diagnostic and Therapeutic Approaches to the Boutonniere
Deformity
Neal B. Zimmerman
Ryan M. Zimmerman
Rebecca J. Saunders
Michael A. McClinton
IDENTIFICATION OF THE BOUTONNIERE DEFORMITY

The normal extensor mechanism is composed of an interconnected network of the subdivisions and reinforcing
structures of the extensor mechanism surrounding the proximal interphalangeal (PIP) joint. Just proximal to the
PIP joint, the extensor mechanism divides into three components. The central slip continues distally to insert into
the base of the middle phalanx. The other two limbs diverge from the central slip to insert in the lateral bands,
which lie dorsal to the PIP joint center of rotation. The lateral bands are secured in position palmarly by the
transverse retinacular ligaments and dorsally by the triangular ligament. Abnormalities of these structures are
necessary components of a boutonniere deformity, as will be explained below. The transverse retinacular
ligaments run
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palmarly from the lateral bands to the volar aspect of the PIP joint and the volar plate. The oblique retinacular
ligaments arise from the volar aspect of the PIP joint and flexor sheath to pass dorsally and insert into the
terminal tendon as it nears its insertion into the dorsal base of the distal phalanx. They are thought to link
extension of the proximal and distal interphalangeal (DIP) joints. Distal to the central slip insertion resides the
triangular ligament, a thin translucent sheet that passes over the dorsum of the middle phalanx and functions to
tether the lateral bands in their normal dorsal position (Figs. 11-1, 11-2, 11-3 and 11-4).
A wide variety of traumatic insults can disrupt the central slip insertion into the base of the middle phalanx. It is
important to recognize that injury of the central slip of the extensor mechanism is not synonymous with a
boutonniere deformity. Indeed, central slip injury is a necessary
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precursor, but alone does not create a boutonniere deformity. Other necessary components to the development
of the deformity are palmar migration of the lateral bands and attenuation of the triangular ligament. Following
injury of the central slip, if full motion of the digit is continued, as in a neglected or unrecognized injury, proximal
migration of the central slip causes reactive overpull through the lateral bands in an attempt to extend the PIP
joint. This results in attenuation of the triangular ligament and palmar migration of the lateral bands, which
eventually migrate palmar to the axis of PIP joint rotation. Augmented pull through the lateral bands is also
responsible for exaggerated extensor tone at the distal joint. As they migrate palmar to the axis of rotation of the
PIP joint, the lateral bands reverse their effect and act as flexors rather than extensors of the PIP joint. The
summation of these pathologic changes is the development of a boutonniere deformity, which is the subacute to
chronic digital deformity of PIP extension lag with DIP hyperextension (Fig. 11-5).
FIGURE 11-1 Lateral (A) and dorsal (B) views of the digit showing components of the extensor mechanism.
Structures involved in the pathophysiology of the boutonniere deformity are marked (*). (Illustration by Elizabeth
Martin © 2011. Reprinted with permission from Green's Operative Hand Surgery. 6th ed. Philadelphia, PA:
Elsevier, 2011.)
FIGURE 11-2 Lateral view of the PIPJ showing the central slip insertion, triangular ligament, terminal tendon,
lateral band, and the transverse retinacular ligaments. (Illustration by Elizabeth Martin © 2011. Reprinted with
permission from Green's Operative Hand Surgery. 6th ed.)
FIGURE 11-3 Dorsal schematic view of the PIPJ indicating components of the extensor mechanism. (Illustration
by Elizabeth Martin © 2011. Reprinted with permission from Green's Operative Hand Surgery. 6th ed.)
FIGURE 11-4 Dorsal view of the PIPJ in a cadaveric specimen. (A) Central slip insertion into the base of the
middle phalanx, (B) triangular ligament, (C) terminal tendon insertion into the base of the distal phalanx.
(Photograph courtesy of Dr. Thomas M. Brushart.)
The key to effective treatment of central slip disruption and avoidance of the development of boutonniere
deformity is early recognition. Indeed, since the boutonniere deformity progresses from central slip injury to the
complex deformity over time, this interlude allows the majority of cases to be treated without surgery. When the
central slip is initially disrupted, there is no clinical deformity of the digit. The person is able to make a full fist and
to extend the PIP joint, albeit with diminished extensor power, because the lateral bands are intact and still dorsal
to the axis of rotation. The most effective way to screen for a central slip disruption is Elson's test (1,2). We
recommend that this maneuver be performed on any patient who presents with a swollen, tender PIP joint
following injury. The magnitude of trauma required to disrupt the central slip is highly variable, as is the
mechanism of injury. Although boutonniere deformity is classically taught to be an injury involving forced flexion
on an extended PIP joint, a different mechanism should not allay concern. An elevated index of suspicion should
be held for any injury to the area of the PIP joint. Every finger sprain needs to be evaluated with this specific
testing to evaluate the competence of the central slip.
Elson's test is carried out by flexing the patient's finger to 90 degrees of flexion at the PIP joint. This is typically
done using the edge of the exam table. The person is then asked to attempt forceful PIP extension while the
examiner resists the person's extension effort. In the normal situation, substantial extensor tension is generated
at the PIP joint with a very little force generated at the distal joint. This makes sense, because the extensor
system is intact, and the lateral bands cannot extend the DIP joint without the central slip also extending the PIP
joint, which is being blocked by the examiner. With disruption of the central slip, the opposite occurs. Diminished
extensor tone is seen at the PIP joint with prominent or even exaggerated extensor force at the distal joint. This
finding is also commonsense, as the disrupted central slip can now retract further than usual, whether or not the
PIP joint is blocked, transmitting force
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to the terminal tendon through the lateral bands (1,3,4) (Fig. 11-6). The pseudo-boutonniere deformity is caused
by a hyperextension injury of the PIPJ resulting in a flexion contracture without injury to the central slip and
resultant lateral band migration and tightening. This can lead to stretching of the central slip over time resulting in
decreased PIP extension. Unlike the boutonniere deformity, there is no disruption of the extensor mechanism.
Testing with Elson's maneuver will show good extension force at the PIPJ and little force at the DIPJ, as seen in
the normal situation (5).
FIGURE 11-5 The pathomechanics of the development of a boutonniere deformity. After disruption of the central
slip (A), the lateral bands migrate palmar to the axis of rotation of the PIP joint due to attenuation of the triangular
ligament. Overpull through the lateral bands due to their new, volar position causes exaggerated extensor tone at
the DIP joint and flexion of the PIP joint (B). (From Wolfe SW, Hotchkiss RN, Pederson WC, et al., eds.: Green's
Operative Hand Surgery. 6th ed. Philadelphia, PA: Elsevier, 2011. With permission from Elsevier.)
FIGURE 11-6 Elson's test is carried out by flexing the PIPJ to 90 degrees, typically over a hard surface such as a
table. The patient is then asked to attempt to extend his or her PIPJ. With an intact central sip (A), there is good
extensor tone at the PIPJ and little extensor force generated at the DIPJ. If the central slip is disrupted (B), there
is decreased extensor force at the PIPJ and prominent extensor tone at the DIPJ. The red dot indicates the
center of rotation of the PIP joint. Note the position of the lateral bands palmar to the axis of rotation in B.
The differential diagnosis of a swollen, painful PIP joint includes central slip disruption, fracture (of either the
bony portion of the middle phalanx encompassing the central slip insertion or elsewhere), collateral ligament
injury, volar plate damage, capsular sprain, inflammatory or crystalline arthropathy, as well as infection.
PEARLS AND PITFALLS

Acute central slip injury, the inciting factor in a boutonniere deformity, often presents with no clinical deformity.
Disruption of the central slip may not be initially clinically evident and needs to be suspected and tested for.
Examine every injured PIP joint using Elson's test to determine central slip integrity.
Failure of the central slip leads to diminished extensor power at the PIP joint and increased extensor power at
the DIPJ during Elson's test.
Untreated central slip injuries result in volar migration of the lateral bands, attenuation of the triangular
ligament, and development of the boutonniere deformity.
EARLY CLINICAL MANAGEMENT

Each case of a suspected central slip injury should be evaluated radiographically, including orthogonal views of
the injured digit, in addition to the clinical examination described above. The vast majority of acute and chronic
boutonniere deformities can be treated nonsurgically with acceptable results. It is worthwhile to remember that a
mild extensor lag at the PIP joint is commonly not a significant impediment to hand function as long as the person
is able to make a nearly full fist with good strength. The overarching goal of all treatments for boutonniere
deformities is to increase deficient extensor tone at the proximal joint and to decrease exaggerated extensor tone
at the distal joint.
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Acute Osseous or Open Injuries
Radiographs may demonstrate an injury to the PIP joint with an osseous fragment, which includes the central slip
insertion. In these cases, the osseous fragment with the contiguous central slip is repaired if feasible with fine
wires or sutures. If the fragment is very small or insufficient for secure fixation, the central slip can be isolated
from the fragment and a bone anchor used to insert it into its normal position at the dorsal base of the middle
phalanx. An open injury of the PIP joint with disruption of the central slip necessitates direct repair by any of a
variety of direct tendon repair techniques or mobilization of local tissues such as the lateral bands, central slip, or
a portion of the flexor digitorum superficialis tendon (Figs. 11-7 and 11-8) (6,7,8,9).
FIGURE 11-7 A variety of techniques can be used to repair an open injury to the extensor mechanism involving
damage to the central slip. (From Wolfe SW, Hotchkiss RN, Pederson WC, et al., eds.: Green's Operative Hand
Surgery. 5th ed. Philadelphia, PA: Elsevier, 2005. With permission from Elsevier.)
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FIGURE 11-8 A turnover flap can be used to reconstruct the central slip if there is loss, or insufficient tissue for
direct repair, as described by Snow, 1973. (From Wolfe SW, Hotchkiss RN, Pederson WC, et al., eds.: Green's
Operative Hand Surgery. 6th ed. Philadelphia, PA: Elsevier, 2011. With permission from Elsevier.)
Acute Closed Soft-Tissue Injuries and Chronic Boutonniere Deformities With a Supple PIP
Joint
If the injury presents acutely or chronically with a fully passively flexible PIP joint, a common protocol is to initiate
treatment with a splint holding solely the PIP joint in full extension. The duration of splinting is variable but
usually comprises 6 to 8 weeks of full-time splinting, followed by nighttime splinting for another 6 weeks. Coupled
with full-time extension of the PIP joint, the patient is asked to actively flex the distal joint. This has the effect of
bringing the lateral bands back dorsal to the axis of rotation of the PIP joint, which serves to stretch the
transverse retinacular ligaments and preclude them from shortening which would trap the lateral bands volar to
the axis of PIP rotation. It also stretches the oblique retinacular ligaments, thus decreasing the tendency for
hyperextension of the DIPJ while promoting gliding of the lateral bands (Fig. 11-9).
The early short arc motion (SAM) protocol can also be used in the management of closed supple boutonniere
injuries. Evans treated 36 people seen within 3 to 4 weeks of injury. Patients were
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initially immobilized in casts for 2 to 3 weeks to reduce edema and improve passive PIP extension. Patients were
asked to perform a 30- to 40-degree arc of active PIP flexion in therapy two times per week under direct
supervision. The PIP was splinted in full extension at all other times. Patients were seen for 8 weeks, and the
average PIP flexion at discharge was 92 degrees with an extension lag of -6 degrees. Average DIP flexion was
47 degrees (10). Utilization of the SAM protocol advocates for an earlier return to function by decreasing the
duration of therapy due to the development of excessive stiffness caused by prolonged immobilization.
Relative motion splinting is another method to support central slip disruptions that can replace or follow a period
of full-time PIP extension splinting. The biomechanics of relative motion flexion splinting are intriguing (11). A
relative motion flexion splint maintains the MCP joint of the injured digit in 15- to 20-degrees of flexion relative to
the other fingers, while allowing full active extension of the other MCP joints (Fig. 11-10). The flexed posture of
the MCP joint serves to protect the nascent boutonniere deformity (12). With relative flexion of the MCP joint, the
lateral bands relax because of decreased intrinsic tone. This allows the lateral bands to migrate dorsal to the PIP
joint center of rotation when they are drawn distally by DIP flexion. Further, the long extensor tendons directly
pull the lateral bands dorsally via the lateral slips, which are subdivisions of the extensor mechanism connecting
the extrinsic extensors to the lateral bands (12). Conversely, when full MP extension is allowed, the lateral bands
are pulled palmarly by augmented intrinsic muscle tone and tightening of the transverse retinacular ligaments.
Also, the relatively lax extrinsic extensors relax their dorsal support on the lateral bands through the lateral slips.
Relative motion flexion splint technique requires that the PIP joint can be passively extended to neutral. The
relative motion flexion splint is used during the day and a static PIP extension splint at night. If loss of extension
is noted with exercises during the day, intermittent use of a static PIP extension splint is recommended as well
during the daytime. Several surgeons have reported
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generally favorable results following 6 to 8 weeks of full-time boutonniere splinting with 2 months of relative
motion flexion splinting (11,12,13).
FIGURE 11-9 Showing a patient in a splint with the PIPJ in full extension flexing the DIP to stretch the transverse
retinacular ligaments and encourage the lateral bands to remain dorsal to the axis of rotation of the PIP joint.
FIGURE 11-10 Photos of patient wearing a relative motion flexion splint of the ring finger, which maintains the
MCPJ of the involved finger in a relatively flexed posture compared to adjacent digits.
Chronic Deformity With a Stiff PIP Joint

Surgical reconstruction of the chronic boutonniere deformity can only be considered in the presence of a supple
PIP joint. If the PIP joint lacks full passive extension at presentation, initial treatment is therapy directed toward
reestablishing a full arc of PIP joint motion. Patients who present with a fixed PIP flexion contracture greater than
30 degrees require serial casting until passive extension to neutral is obtained. Severely swollen joints usually
respond well to the gentle circumferential pressure provided by casting. Patients need to be seen in therapy
frequently to monitor the cast fit as edema subsides. Less severe contractures respond well to other methods of
static progressive orthoses to increase PIP extension. Orthotic use or casting should be continued until neutral
extension is achieved, or there is a plateau in passive extension. Once maximum extension has been achieved,
the patient needs to be immobilized in the extended position for 4 to 6 weeks prior to gradual remobilization into
flexion. Once active PIP flexion is initiated, it is important to monitor the effects of the flexion exercises on the
patient's extension lag. Orthotic use between exercise sessions and at night is continued for an additional 6 to 8
weeks.
PIP stiffness recalcitrant to therapy and splinting can be treated with capsulectomy and subsequent therapy to
maintain motion. PIP contractures that persist after capsulectomy can be managed with implant arthroplasty or
arthrodesis. If a significant extensor lag recurs following capsulectomy, full-time splinting is reinitiated. Often, at
the conclusion of a prolonged course of splinting, the patient will be left with a mild extensor lag (often
approximately 20 degrees) at the PIP joint. This degree of deformity is often acceptable to them if they are able
to make a good fist. Also, discussion with the patient should include the information that even in a boutonniere
deformity treated surgically, a 20-degree extensor lag with a good arc of flexion of the PIPJ is an acceptable
result, which is not uniformly achieved (Fig. 11-11).
FIGURE 11-11 An algorithmic approach to the pre- and nonsurgical treatment of the acute and chronic central
slip and boutonniere deformities. (Copyright © The Curtis National Hand Center, 2015.)
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Pearls and Pitfalls
The majority of boutonniere deformities can be treated nonsurgically.
Bony or open injuries of the central slip insertion should be treated surgically.
A minimum of 6 weeks of full-time PIPJ extension splinting is needed.
The DIPJ should be actively flexed while the PIPJ is immobilized in extension.
Mild extensor lag at the PIPJ is functionally well tolerated.
SURGICAL RECONSTRUCTION OF THE CHRONIC BOUTONNIERE

DEFORMITY
The literature, including many textbooks, abound with descriptions of numerous techniques to deal with the
chronic boutonniere deformity. As is often the case when multiple options exist, none has been proven superior
and the sheer number of options can readily obfuscate principles of treatment. What follows is the authors'
preferred treatment algorithm and not a comprehensive historical review of options. Broadly, we prefer Curtis'
staged approach (14) as outlined below. We suggest that as readers develop their own preferences, they
maintain a standardized, sequential approach to these cases. We hope this approach guides readers in a logical
approach to a challenging surgical problem.
We consider a supple PIP joint to be an absolute prerequisite for surgery. If a 20- to 30-degree extensor lag in a
supple digit is unacceptable to the patient, we begin with tenolysis of the central slip and transverse retinacular
ligaments. We recommend an extensile dorsal approach to the PIP joint with the patient under local anesthesia
to participate in the surgical procedure. Although these first steps may seem relatively minor, significant
deformities can sometimes be corrected by this intervention alone. In his classic paper, Curtis et al. (1983)
demonstrated correction of a 50-degree extensor lag using solely tenolysis (14). If an extensor lag persists, the
next step is division of the transverse retinacular ligaments. This liberates the lateral bands from their stout volar
tethers, hopefully allowing them to drift dorsal to the PIP axis of rotation and again function as extensors rather
than flexors of the PIP joint. The patient is again asked to actively extend the joint and the procedure terminated
if full extension has been restored.
Should an extensor lag still persist, its magnitude determines the next step. If the deformity is less than 20 to 30
degrees, a distal extensor tenotomy, as popularized by Fowler (15,16), is a reliable and predictable procedure to
regain some, but not usually complete extension of the PIP joint. This procedure, in essence, creates a surgical
mallet finger. Although a mallet finger is mechanically created, a mallet deformity does not result due to the
preservation of the oblique retinacular ligaments, which serve to link extension of the PIP joints and DIP joints.
This procedure is composed of division of the extensor mechanism at the level of the junction of the proximal and
middle thirds over the middle phalanx, distal to the triangular ligament. The oblique retinacular ligaments that
extend from volar plate of the PIP joint to the distal joint are identified (if possible) and preserved. Once the
extensor mechanism is divided, the entire extensor hood slides proximally, thereby increasing extensor tone at
the PIP joint (Figs. 11-12, 11-13, 11-14 and 11-15).
A residual extension lag at the PIP joint of greater than 30 degrees following division of the transverse retinacular
ligaments obligates the surgeon to evaluate whether the central slip remnant is robust and long enough to
mobilize and advance into the base of the middle phalanx. We are unaware of any objective methods to make
this determination; it is instead based on the surgeon's judgment. If deemed possible, the central slip is mobilized
and advanced 4 to 6 mm into the middle phalanx and secured with an osseous anchor. The lateral bands are
then sewn loosely to one another and to the reinserted central slip (Fig. 11-16). In his classic paper, Curtis et al.
(1983) reported the outcomes on 23 patients managed with this algorithm. Preoperative extension lag of 41
degrees was reduced to 10 degrees in seventeen patients who required tenotomy, and an extension lag of 55
degrees was improved to 17 degrees in six patients who required central slip reinsertion (14). Despite over 30
years since this paper was published, we are unaware of further work studying an algorithm (as opposed to an
application of a particular technique) for managing the boutonniere deformity (Fig. 11-17).
Various methods of reconstruction exist if the central slip cannot be reinserted into the middle phalanx, either due
to retraction or tissue loss. Urbaniak et al. used only local tissue for reconstruction. They recommended raising a
double-layered flap of capsule and synovium at the PIP joint to augment the damaged central slip insertion. They
reported good results in 8 of 13 patients, and their only poor result was in a patient with an intra-articular fracture
(17) (Fig. 11-18). Littler recommended separating the lateral bands from the oblique retinacular ligaments and
securing them to the attenuated central slip remnant (18) (Fig. 11-19). Matev divided both lateral bands, but at
different levels. He transferred the shorter to the native central slip insertion and transposed the longer one
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to the contralateral terminal tendon insertion. This technique uses one lateral band to reconstruct the central slip
and the other to lengthen (but not fully release, as occurs with a distal tenotomy) the terminal extensor tendon
(19) (Fig. 11-20). Terrill and Groves reviewed 20 consecutive patients who underwent the Matev procedure
slightly modified by their incision choice. Of note, 14 of 20 patients had supple PIP joints at the time of surgery
while six had a PIP flexion contracture. Good or satisfactory results were achieved in 85% of the patients with
supple PIP joints preoperatively and 67% of those with a preoperative PIP contracture (20). Littler also described
the use of a free tendon graft through the distal portion of the intact extensor mechanism into the base of the
middle phalanx to reconstitute the central slip (21) (Fig. 11-21). Li et al. (2014) compared central slip
reconstruction using a turndown of native tissue versus palmaris graft and found the native tissue turndown was
superior (22). For this reason and others, the authors do not recommend tendon grafting for reconstruction of the
central slip unless there are no other reasonable options.
FIGURE 11-12 Fowler distal tenotomy for a mild boutonniere deformity. The tenotomy is carried out proximal to
the triangular ligament to preserve the dorsal tether of the lateral bands. A: Location of the tenotomy distal to the
central slip insertion maintaining the integrity of the triangular ligament. B: Proximal migration of the extensor
hood. C: Rebalancing of the extensor apparatus after proximal migration of extensor hood.
FIGURE 11-13 The central slip insertion into the base of the middle phalanx is indicated by “C”; the location of
the division of the extensor mechanism for a Fowler central slip tenotomy is indicated by the arrow. Note the
triangular ligament (T) distal to the indicated tenotomy site.
FIGURE 11-14 The Penfield retractor is lifting the oblique retinacular ligament, which is seen inserting into the
terminal extensor tendon. This structure is retained after a Fowler central slip tenotomy and is partly responsible
for extension of the DIP joint.
FIGURE 11-15 A central slip tenotomy has been performed in this patient with a supple boutonniere deformity.
The arrow indicates the tenotomy distal to the triangular ligament and the central slip insertion. “C” indicates the
central slip insertion and “T” the triangular ligament.
FIGURE 11-16 A 20 year-old collegiate football player sustained an acute central slip injury that progressed to a
chronic boutonniere deformity over several months as he completed the season before seeking treatment. A
course of splinting was needed to obtain full passive extension prior to undergoing the surgical reconstruction
shown above. A dorsal Brunner incision is outlined with the apex at the level of the PIP joint (A). A flap is
elevated down to the retinacular layer and reflected to reveal the subluxated lateral band (asterisk) (B). The
transverse retinacular ligaments are tenolysed and divided to liberate the lateral bands (asterisk) (C, D). After
separating the lateral bands and incompetent triangular ligament, the avulsed central slip (double asterisk) is
clearly seen (E).The native central slip insertion is roughened and insertion sites for two bone anchors are
marked (F).
FIGURE 11-16 (Continued) Bone anchors are placed and sutures passed through the central slip in horizontal
mattress fashion (G). The sutures are tied, reducing the central slip to its native insertion (H). The lateral bands
(asterisk) are reefed together, restoring their native, dorsal position (I). The resting posture of the finger reveals
full PIP extension at the conclusion of the case (J).
FIGURE 11-17 Curtis' algorithmic approach to boutonniere reconstruction. Stages I and II consist of tenolysis of
the central slip and transverse retinacular ligaments followed by division of the transverse retinacular ligaments if
needed. Stage III is the Fowler tenotomy, and stage IV is mobilization and advancement of the central slip
followed by dorsal imbrication of the lateral bands to the advanced central slip. (From Curtis RM, Reid RL,
Provost JM: A staged technique for the repair of the traumatic Boutonniere deformity. J Hand Surg [Am] 8(2):
167-171, 1983. With permission from Elsevier.)
FIGURE 11-18 Urbaniak's technique of central slip reconstruction using joint capsule and local tissue illustrating
elevation of a proximally based flap (A) and layering of this flap over tissue raised from the base of the middle
phalanx (B). (From Urbaniak JR, Hayes MG: Chronic boutonniere deformity—an anatomic reconstruction. J
Hand Surg 6(4): 379-383, 1981. With permission from Elsevier.)
FIGURE 11-19 Littler described division and dorsal transposition of the lateral bands to central slip remnant to
increase extensor force at the PIP joint. (From Bates SJ, Chang J: Repair of the extensor tendon system. In:
Thorne CH, Bartlett SP, Beasley RW, et al., eds. Grabb and Smith's Plastic Surgery. 6th ed. Philadelphia, PA:
Lippincott Williams & Wilkins, 2006.)
FIGURE 11-20 Matev's technique to reconstruct the central slip involves dividing the two lateral bands at
different levels (A). The shorter lateral band is attached to the remnant of the central slip insertion, and the
longer lateral band is sutured to the contralateral terminal tendon (B).
Ohshio et al. described using yet another tissue option for reconstruction: the transverse retinacular ligaments.
They recommended release of the volar attachment of each transverse retinacular ligament and then flipping
them dorsally and sewing them to one another. This forces the lateral bands to become extensors of both the
PIP and DIP joints. Of note, loss of PIP flexion can occur with this technique, and it is contraindicated with
contracted lateral bands (23). Even more creatively, Ahmad rerouted a slip of the flexor digitorum superficialis
tendon through the middle phalanx onto the dorsal surface and sewn to the proximal stump of the central slip (9).
Of note, Klasson et al. (1992) evaluated biomechanically a number of chronic boutonniere reconstructions and
found they were all similar and biomechanically sufficient. We agree with the authors that the preoperative status
of the finger is likely a key determinant of surgical outcome (24) (Fig. 11-22).
Although we advocate making the final decision of reconstructive technique intraoperatively after evaluation of
the tissue available, we prefer the Matev technique (19) when the central slip cannot be reinserted and avoid the
use of tendon grafts. The challenges of any soft-tissue procedure to reconstruct the extensor apparatus are
proper balancing and knowing when sufficient correction has been achieved, and reconstruction of a chronic
boutonniere is no exception. Surgeons have traditionally relied on their subjective judgment to determine the
extent of soft-tissue releases needed
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to rebalance a boutonniere, manipulating the digit or observing the tenodesis effect or the resting cascade in a
manner of personal preference. Recently, wide awake hand surgery (also referred to as wide awake local
anesthesia no tourniquet or WALANT) has garnered significant attention and support as a way to obtain real-
time feedback on procedures such as tendon repairs or transfers (13). Although we are unaware of any papers
specifically discussing it, reconstruction of a chronic boutonniere may benefit substantially from these techniques
(12).
FIGURE 11-21 Littler advocated using a free tendon graft to reconstitute the central slip if adequate local tissue
is not present.
FIGURE 11-22 The authors' suggested algorithmic approach to surgical treatment of the boutonniere deformity.
(Modeled after Curtis RM, Reid RL, Provost JM: A staged technique for the repair of the traumatic boutonniere
deformity. J Hand Surg Am 8(2): 167-171, 1983. Copyright © The Curtis National Hand Center, 2015.)
FIGURE 11-23 The patient is performing short arc flexion and extension of the PIP joint with the help of a
template splint.
Central slip repairs, whether they are simple or complex injuries, are effectively managed using the SAM, or early
SAM protocol (25). This protocol allows 30 degrees of active PIP flex with an active extension component within
a few days of the operative procedure. Thirty degrees of motion was found to be great enough to prevent tendon
adherence over the proximal phalanx without compromising the central slip repair integrity. Early motion is
thought to prevent the deleterious effects of prolonged immobilization of the PIPJ. This technique has been
shown to provide superior results in regard to total active range of motion, decreased extension lag, time to
discharge from therapy, and earlier return to work for both simple and complex injuries when compared to the
traditional management of immobilization for 6 to 8 weeks. Simple template splints are used to guide the patient
in performing the correct amount of motion at each joint. The PIP is splinted in neutral at all times when not
performing the prescribed exercises. The arc of motion for the PIP joint is increased 10 degrees each week after
the 2nd postoperative week as long as the patient is not developing an extension lag. The arc of flexion is
increased by 10 degrees per week if the patient is able to maintain their active extension. The use of the PIP
extension splint is weaned during the day between 6 and 8 weeks after surgery, and night splinting is continued
for a few additional weeks (26) (Fig. 11-23).
PEARLS AND PITFALLS

Follow an algorithmic approach to these challenging surgical reconstructions.
Test digital motion frequently, ideally in a wide awake patient, after each stage of correction.
We prefer Dr. Curtis' staged approach and use the Matev technique of lateral band divisions and transfers
when the central slip cannot be reinserted.
Patients should be counseled that a mild extensor lag or loss of flexion can be the final result after complex
reconstruction. Surgeons should be wary of operating on patients with unrealistic expectations.
COMPLICATIONS
Stiffness of the digit following either surgical or nonoperative treatment of the boutonniere deformity is by far
the main complication. It is important to remember that a mild extensor lag is functionally far less of an
impairment than a digit with limited flexion. Thus, attempts to increase extensor power at the PIP joint
should be tempered with caution.
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REFERENCES
1. Elson RA: Rupture of the central slip of the extensor hood of the finger. A test for early diagnosis. J Bone
Joint Surg (Br Vol) 68(2): 229-231, 1986.
2. Vermaak P, Devaraj V: Don't slip up! A modified technique for assessing central slip injuries. J Bone Joint
Surg (Eur Vol) 37(9): 893-895, 2012. doi: 10.1177/1753193412439273
3. Rubin J, Bozentka DJ, Bora FW: Diagnosis of closed central slip injuries. A cadaveric analysis of non-
invasive tests. J Hand Surg Br 21(5): 614-616, 1996. doi: 10.1016/S0266-7681(96)80142-2
4. Venus MR, Little C: The modified Elson's test in open central slip injury. Injury Extra 41(11): 128-129,
2010. doi: 10.1016/j.injury. 2010.08.039
5. McCue FC, Honner R, Gieck JH, et al.: A pseudo-boutonniere deformity. Hand 7(2): 166-170, 1975.
6. Green DP, Hotchkiss RN, Pederson WC, et al., eds: Green's Operative Hand Surgery. 5th ed. Vol. 1.
Philadelphia, PA: Elsevier Churchill Livingstone, 2005: 200-203.
7. Snow JW: Use of a retrograde tendon flap in repairing a severed extensor in the pip joint area. Plast
Reconstr Surg 51(5): 555, 1973.
8. Aiache A, Barsky AJ, Weiner DL: Prevention of the boutonniere deformity. Plast Reconstr Surg 46(2): 164-
167, 1970.
9. Ahmad F, Pickford M: Reconstruction of the extensor central slip using a distally based flexor digitorum
superficialis slip. J Hand Surg Am 34(5): 930-932, 2009. doi: 10.1016/j.jhsa.2009.01.025
10. Evans RB: Clinical management of extensor tendon injuries: The therapist's perspective. In: Skervin TM,
Osterman AL, Fedorczyk J, et al., eds. Rehabilitation of the Hand and Upper Extremity. 6th ed. Philadelphia,
PA: Mosby, 2011.
11. Merritt WH: Relative motion splint: active motion after extensor tendon injury and repair. J Hand Surg Am
39(6): 1187-1194, 2014. doi: 10.1016/j.jhsa.2014.03.015
12. Lalonde DH: How wide awake surgery changed my practice. Curtis National Hand Center. 2014; 77
minutes.
13. Lalonde DH, Kozin S: Tendon disorders of the hand. Plast Reconstr Surg 128(1): 1e-14e, 2011. doi:
10.1097/PRS.0b013e3182174593
14. Curtis RM, Reid RL, Provost JM: A staged technique for the repair of the traumatic boutonniere deformity.
J Hand Surg Am 8(2): 167-171, 1983. doi: 10.1016/S0363-5023(83)80009-4
15. Fowler SB: Fowler: extensor apparatus of the digits. J Bone Joint Surg Br 31:477,1949.
16. Houpt P, Dijkstra R, Van Leeuwen JS: Fowler's tenotomy for mallet deformity. J Hand Surg Br 18(4): 499-
500, 1993.
17. Urbaniak JR, Hayes MG: Chronic boutonniere deformity—an anatomic reconstruction. J Hand Surg Am
6(4): 379-383, 1981. doi: 10.1016/S0363-5023(81)80048-2
18. Littler JW, Eaton RG: Redistribution of forces in the correction of Boutonniere deformity. J Bone Joint
Surg Am 49(7): 1267-1274, 1967.
19. Matev I: Transposition of the lateral slips of the aponeurosis in treatment of long-standing “boutonniere
deformity” of the fingers. Br J Plast Surg 17: 281-286, 1964.
20. Terrill RQ, Groves RJ: Correction of the severe nonrheumatoid chronic boutonnière deformity with a
modified Matev procedure. J Hand Surg Am 17(5): 874-880, 1992.
21. Littler JW: The digital extensor-flexor system. Reconstructive Plastic Surgery. Philadelphia, PA: W.B.
Saunders Company, 1977: 3174-3175.
22. Li Y, Ding A, He Z, et al.: Comparison of proximal turndown of central slip combined with suture of lateral
bands versus free tendon grafting for central slip reconstruction after an open finger injury. Acta Orthop Belg
80(1): 119-125, 2014.
23. Ohshio I, Ogino T, Minami A, et al.: Reconstruction of the central slip by the transverse retinacular
ligament for boutonnière deformity. J Hand Surg Br 15(4): 407-409, 1990.
24. Klasson SC, Adams BD: Biomechanical evaluation of chronic boutonnière reconstructions. J Hand Surg
17(5): 868-874, 1992.
25. McAuliffe JA: Early active short arc motion following central slip repair. J Hand Surg Am 36(1): 143-146,
2011. doi: 10.1016/j.jhsa.2010.10.007
26. Evans RB: Early active short arc motion for the repaired central slip. J Hand Surg Am 19(6): 991-997,
1994. doi: 10.1016/0363-5023(94)90103-1
Chapter 12
Strategies for Handling the Flexible Fixed Swan-Neck Deformity
Kenneth Robert Means Jr
INTRODUCTION
Swan-neck deformity of the fingers is defined as proximal interphalangeal (PIP) hyperextension and distal
interphalangeal (DIP) flexion. Concomitant metacarpophalangeal (MCP) flexion deformity is possible though it is
not a requisite feature. Fortunately, hand surgeons today do not frequently encounter debilitating swan-neck
deformities in patients. This is especially true due to the recent advent of disease-modifying antirheumatic drugs
(DMARDs) that have revolutionized the care of many rheumatologic conditions and prevented many crippling
extremity deformities, including swan-neck posturing of the digits. Systemic lupus erythematosus (SLE) is the
classic rheumatologic condition that causes flexible swan-neck deformities, but other conditions can lead to this
problem as well (Fig. 12-1). Unfortunately, a lack of familiarity with swan-neck deformities on the surgeon's part
may lead to uncertainty when treating patients with this potentially complex problem. This is likely particularly
true for younger surgeons who may not have as much experience, due to the use of DMARDs, with the many
possible presentations, pathologies, and treatment options for these deformities. Part of the challenge of treating
patients with swan-neck deformity is that, unlike boutonniere deformity that by definition originates at the PIP
joint, swan-neck deformity can originate at the wrist, MCP, PIP, or DIP joints, and often, there is pathology at
more than one joint contributing to the deformity. One of the first things surgeons should try to determine when
treating a patient with a swan-neck deformity is the underlying pathologic and anatomic cause of the deformity;
knowing this will help guide treatment. Surgeons typically start correction of swanneck deformity at the most
proximal involved joint and progress distally either at the same surgical setting or in stages.
Today, hand care professionals are most likely to see patients present with swan-neck deformities as the result
of trauma, such as a mallet finger injury or PIP joint dislocation. Swan-neck posturing after these types of injuries
is typically not as severe as that with rheumatologic conditions. These patients may have clinically insignificant
swan-neck posturing in which they are still able to actively initiate PIP joint flexion, and the deformity may be
more of a cosmetic concern. In these cases, the main focus is on preventing worsening of the deformity, which
could then lead to significant
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functional limitation. This entails the use of a PIP dorsal block or figure-of-eight splint to prevent hyperextension
but still allow flexion. Intrinsic stretches are also helpful if the patient demonstrates significant intrinsic tendon
tightness. The main functional limitation for patients with clinically significant flexible or fixed swan-neck deformity
is their inability to flex the PIP joint. For patients with flexible deformity, this means that they have to use their
other hand or place the dorsum of the affected digit against something in order to initiate active PIP flexion. For
patients with fixed deformity, the PIP joint is by definition in a hyperextended and contracted position and unable
to flex even passively beyond this point. Other causes of clinically significant swan-neck deformity include more
severe trauma such as hand crush injuries with severe intrinsic contractures, burns with dorsal skin and soft-
tissue contractures, neuromuscular conditions with hand intrinsic muscle spasticity and eventual joint
contracture, and patients at varying places along the spectrum of generalized hyperextensibility. Evaluation and
treatment of these more rare and specialized causes of swan-neck deformity are beyond the scope of this
chapter.
FIGURE 12-1 Patient with SLE and several fingers with tendencies toward swan-neck deformity, most
pronounced in the small finger where the patient is unable to actively initiate PIP flexion.
There have not been many recent changes in the nonoperative and operative management of swan-neck
deformity. Authors have reported recent results with different techniques as well as modifications to some of the
techniques (1). In this chapter, I present what I believe to be the most effective surgical techniques for the most
commonly encountered swan-neck pathologies. I have also sought the collective experience and wisdom from all
of the surgeons at our hand center and will acknowledge many of their tips throughout the chapter to further this
cause. I am of course also indebted to the authors of the excellent chapter in the previous edition of this text and
draw on their observations and recommendations here as well (2).
INDICATIONS
Patients with functional issues due to the swan-neck deformity for which splints are ineffective or
impractical; in most cases, surgical intervention will not increase the overall range of motion for the finger
but will make the range of motion take place in a more functional arc.
Patients with progressive deformity that may lead to functional deficits; this involves more of a
preventative approach, such as treating an acute or chronic mallet injury in order to prevent further
progression of the swan-neck deformity.
Patients with flexible deformities are, by definition, fully passively correctable; for these patients, soft-
tissue reconstruction options are indicated.
Patients with fixed deformities are indicated for joint release followed by soft-tissue reconstruction only if
the articular surfaces are in acceptable condition. Arthrodesis or arthroplasty is indicated when the
articular surfaces are not in acceptable condition.
CONTRAINDICATIONS
Patients who cannot reliably follow postoperative instructions including a therapy protocol
Patients with severe medical comorbidities or infection that preclude surgical intervention
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The most important part of the preoperative preparation for patients with flexible swan-neck deformities is to
determine the primary, and any secondary, cause(s) of the deformity. This is typically achieved through a
good history and physical exam. During the history, the surgeon should determine the timing and sequence of
development of the deformity, any discrete pain locations, the presence of significant mechanical issues such
as joint(s) locking or being unstable in certain positions, history of trauma or other surgical procedures, and
how the deformity is impacting the patient's life. During the physical exam, the surgeon is looking for any joints
that are synovitic from the wrist to the DIP joint, the resting and active posture of the digit including the joints
that are most significantly contributing to the deformity, the condition of the skin and soft-tissue envelope for
the finger, tenderness at any joints, the suppleness of any deformities, and any flexor or extensor mechanism
abnormalities including assessment of extrinsic extensor or flexor tightness and utilizing the Bunnell test to
reveal any intrinsic tightness. Providers should obtain x-rays of all the joints of the involved fingers as well as
the hand and wrist of the patient. The classic and still most commonly used swan-neck classification scheme
is that of Nalebuff where type I is a flexible PIP hyperextension deformity; type II is secondary to intrinsic
tightness; type III is a fixed PIP joint extension contracture that is “intrinsic” to the joint itself, that is, the
contracture does not change regardless of the degree of flexion or extension of the MCP or any other joints;
and type IV is a swan-neck deformity associated with significant PIP joint degenerative changes.
Of course, patients with rheumatologic conditions require special preoperative considerations, such as
medication and cervical spine management, which are typically coordinated between the surgeon,
rheumatologist, and anesthesia providers. At our institution, we have a protocol based on input from
anesthesia, orthopedic spine surgery, and our hand center for cervical spine management: all patients with
inflammatory arthropathies that may affect cervical spine stability obtain cervical spine x-rays consisting of A/P,
lateral, and flexion and extension lateral x-rays a maximum of 1 year before a pending elective extremity
surgery. We typically indicate on the x-ray prescription to include measurements of c1 to c2 translation,
subaxial translation, or presence of basilar invagination. If any of the following are found on these screening
films, then the patient is referred to a physician who treats cervical spine patients, such as PM&R or ortho-
/neurospine surgery, to determine if any further investigations/treatments are needed before proceeding with
elective extremity surgery: subaxial translation of greater than 3 mm, c1 to c2 translation of more than 4 mm,
and any degree of basilar invagination. Depending on the patient's overall presentation, extent of planned
procedures, and other preoperative recommendations, surgeons may perform the swan-neck procedures
under local or regional nerve block or via general anesthesia.
TECHNIQUE
Procedures to Correct MCP-Primary Flexible Swan-Neck Deformity
MCP-primary deformities typically present in patients with inflammatory arthropathies. In these cases, the MCP
synovitis eventually leads to attenuation of the extensor hood, especially the radial sagittal band, and ulnar
translocation of the extensor tendons. The proximal phalanx (P1) progressively migrates palmarly and ulnarly
until the MCP joint is subluxated or even permanently dislocated in this position. As the extensor tendons
become scarred in the ulnar gutter of the MCP joint and the base of P1, the MCP joint rests in a palmar-ulnar
position leading to shortening of the extrinsic and intrinsic extensor mechanisms, especially on the ulnar side of
the finger. This can lead to an increased PIP extension moment and an initially flexible swan-neck deformity. If
the MCP disease is caught before it becomes a fixed situation, then surgical correction at this level may be
enough to correct the swan-neck deformity and prevent it from worsening. However, the tendency toward swan-
neck posturing classically becomes accentuated when surgical attempts are made to correct a fixed MCP
deformity. In these cases, MCP arthroplasty, by correcting the joint subluxation, often effectively lengthens the
digit and consequently further tensions the shortened extrinsic and intrinsic extensor mechanisms. Centralizing
the previously subluxated extensor tendon also increases the extension force at the PIP joint. The combination of
these changes can worsen the swan-neck deformity (Fig. 12-2). In these cases, a central extensor tenolysis and
intrinsic release at the level of the lateral bands can help. If the deformity is still not corrected, one of the lateral
bands may be excised, typically the ulnar side to help counter ulnar drift tendencies. If this still does not achieve
correction, the surgeon may have to shorten the MCP arthroplasty by removing more distal metacarpal or more
proximal P1. The goal at each stage of attempted correction is to not have a resting swan-neck deformity and for
the surgeon to be able to easily passively flex the PIP joint whether the MCP joint is flexed or extended.
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FIGURE 12-2 Rheumatoid arthritis patient who previously underwent MCP silicone arthroplasties with extensor
tendon centralization and subsequently developed a fixed swan-neck deformity of the ring finger.
Procedures to Correct PIP-Primary Flexible Swan-Neck Deformity

Flexor Digitorum Superficialis Tenodesis of the PIP Joint In inflammatory arthropathies, the PIP joint can
become synovitic with subsequent attenuation of the surrounding soft tissues, especially the volar plate or the
dorsal extensor mechanism. If the volar plate is more significantly attenuated, then PIP hyperextension and
swan-neck deformity ensue. If the dorsal extensor mechanism is more significantly affected, then a boutonniere
deformity is the result and is covered elsewhere in this book. As the PIP joint hyperextends and the transverse
retinacular ligament becomes attenuated, the lateral bands become centralized dorsally and lax, which results in
less extensor force at the DIP joint. This, combined with unopposed and even increased flexion force from the
increased tension on the flexor digitorum profundus (FDP), leads to the DIP flexion deformity. Flexor digitorum
superficialis (FDS) tenodesis of the PIP joint is a simple and effective technique to correct a flexible PIP
hyperextension deformity (E.F. Shaw Wilgis, MD and Neal B. Zimmerman, MD, personal communication) (3).
The surgeon should use his or her preferred palmar approach to the finger; I favor a midaxial incision. The C1
and A3 pulleys over the PIP joint are removed. Excursion of the FDS and FDP can be checked at this point to
ensure that a flexor tenosynovectomy or tenolysis is not required. One slip of the FDS is transected just distal to
Camper's chiasm, leaving the middle phalanx (P2) insertion of the slip intact. The proximal end of the slip is then
used to flex the PIP joint to a desired flexion position. We usually expect tendon transfers and tenodeses to
stretch out over time, especially in patients with rheumatologic or other soft-tissue disorders. Therefore, a
prudent amount of PIP flexion contracture is approximately 20 to 30 degrees to try to balance between
preventing recurrence of the deformity and causing a functional limitation due to the contracture. When the
desired degree of PIP flexion is achieved, the slip of FDS is sutured to the proximal phalanx (P1). Either the slip
can be sutured to the edge of the flexor sheath or a suture anchor can be placed in the P1 to which the slip can
be secured. A variation on this technique is similar to the Zancolli FDS volar MCP tenodesis, in this case
transecting a slip of FDS, bringing it through a slit in A2, and suturing it back to itself distally in the desired PIP
flexion position. However, that technique requires more dissection, may be more likely to stretch out over time,
and may cause more adhesions in zone 2. Having said that, I have performed both procedures and both are
certainly acceptable without any clear difference in outcomes in the reported literature; I agree with Dr. Wilgis
and Dr. Zimmerman that the first technique is simpler and effective. In fact, this procedure can also be performed
in the palm with the FDS tenodesis occurring at the A1 pulley level (4). An advantage of using the slip of FDS
rather than a PIP volar plate capsulodesis is that typically, the volar plate is attenuated due to the swan-neck
deformity. A disadvantage of simply tenodesing the PIP joint in flexion is that although it may allow the lateral
bands to be more lateral/palmar than central/dorsal, this may not be enough to correct a significant DIP flexion
deformity.
Lateral Band Relocation Another simple and effective treatment for PIP-primary flexible swan-neck deformity is
to release and relocate the lateral bands, a procedure attributed to Zancolli. The surgeon uses his or her
preferred approach to the dorsum of the finger. I favor an incision that is midaxial at the level of the PIP joint and
then gently swings dorsal/central to the level of the base of P1 proximally and the head of P2 distally. A full-
thickness skin and soft-tissue flap is elevated just above the extensor paratenon, while protecting the dorsal
digital nerve branch. The skin can then be temporarily sutured to the other side of the finger for retraction (Fig.
12-3). The radial and ulnar lateral bands are then tenolysed at the level of the P1 and the PIP joint, incising
between the lateral bands and the central extensor tendon (Fig. 12-4). Gentle manipulation of the PIP joint is
then performed, and if the lateral bands are not mobile enough to slide palmarly, then they can be further
released distal to the PIP joint. This should now allow the lateral bands to slide palmarly during PIP
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flexion provided that the PIP joint capsule and collateral ligaments do not limit flexion (Fig. 12-5A). If these
procedures do not provide enough correction in passive flexion at the PIP joint, then partial collateral ligament
releases and/or central slip lengthening can be performed as well. This alone may be enough to correct the
deformity if a dorsal blocking splint is used postoperatively. However, to try to prevent recurrence of the
deformity, I favor suturing one of the lateral bands to palmar tissue in the desired degree of PIP flexion, again
typically 20 to 30 degrees. The lateral band can be sutured to the flexor sheath or via a suture anchor placed in
P1, in either case, thus acting as a tenodesis. This procedure removes the hyperextension force that the lateral
bands were exerting at the PIP joint, prevents at least one of the lateral bands from returning to a dorsal position,
provides a passive check to PIP hyperextension, and, by leaving the other lateral band to lay in its resting
position and keeping the central slip insertion intact, should prevent the development of a boutonniere deformity.
A variation on this procedure is to create a soft-tissue flap that the palmarly translocated lateral band can
potentially slide through while preventing dorsal translation. This entails using a portion of the flexor sheath to
form the flap at the A3 level, placing the lateral band within this sling, and suturing the flexor sheath flap back on
to itself to capture the lateral band. Alternatively, the lateral band can actually be sutured within the flexor sheath
so that it lies alongside the flexor tendons at the A3 level (Fig. 12-5B). Yet another variation is to suture a portion
of the flexor sheath to the volar plate to create the sling to capture the lateral band. If the skin is too tight and
restricting PIP flexion, it can be left open at the end of the procedure over the distal portion of the incision (5).
FIGURE 12-3 Dorsal finger exposure for lateral band relocation and other procedures.
FIGURE 12-4 Lateral band releases.
FIGURE 12-5 A: Gentle PIP joint manipulation in flexion. B: Lateral band stabilization option that entails
capturing the lateral band within the flexor sheath at the A3 pulley level.
Procedures to Correct DIP-PIP-Primary Flexible Swan-Neck Deformity

Spiral Oblique Retinacular Ligament (SORL) Reconstruction Surgeons typically consider using this
procedure for patients who have significant DIP and PIP flexible deformities in which correction of the PIP joint
alone is likely to leave significant dysfunction. Several tendon transfer or free graft options have been described
for this technique first attributed to Littler, but our preferred method is to use an ulnar lateral band tenodesis as
long as it and the terminal tendon insertion are in good enough condition to do so (James P. Higgins, MD,
personal communication). A curvilinear incision is made over the dorsalulnar aspect of the finger. The apex of the
curved portion of the incision is over the ulnar aspect of the PIP joint, and the proximal and distal dorsal-central
portions of the incision are at the mid-P1 and proximal-P3, respectively. A full-thickness skin flap is elevated over
the paratenon of the extensor mechanism until reaching the radial border of the extensor mechanism. During this
dissection, the dorsal ulnar digital nerve branch is identified and protected. At the level of the radial PIP/distal P1,
the skin flap elevation should be such that the surgeon will be able to identify the radial palmar neurovascular
bundle from the dorsum later in the procedure. The skin flap can then be sewn to the radial-palmar skin of the
finger for retraction. The ulnar lateral band is dissected as a distally based flap of tissue on its insertion into the
conjoined terminal extensor at the dorsal aspect of the distal phalanx by elevating it separately from the
undisturbed radial component. This ulnar lateral band release is created longitudinally along the dorsal-radial
edge of the lateral band and into the triangular ligament at the dorsal PIP joint, staying just ulnar to the central
slip insertion. The proximal aspect of the ulnar lateral band is then transected at the base of the proximal phalanx
and elevated distally, again keeping the distal terminal tendon insertion intact at the dorsal base of P3. A soft-
tissue tunnel is created that passes between the ulnar digital neurovascular bundle and the flexor tendon sheath
on the ulnar aspect of the middle phalanx. A second soft-tissue tunnel is created on the radial aspect of the
finger at the level of the PIP joint, this time between the radial digital neurovascular bundle and the flexor sheath.
A long clamp or tendon passer is passed from the proximal-radial tunnel to the distal-ulnar tunnel, being careful
to protect the neurovascular bundle at each location. The free proximal end of the ulnar lateral band is clamped,
and the clamp and lateral band are withdrawn to the level of the proximal-radial tunnel at the PIP joint. In this
way, the ulnar lateral band transfer does not compress the ulnar or radial neurovascular bundles and lies
superficial to the flexor sheath. The transferred lateral band is then tensioned proximally to provide approximately
30 degrees of PIP flexion while keeping the DIP joint in neutral extension. When the desired position is reached,
the transferred ulnar lateral band is secured to the radial aspect of the proximal phalanx with a suture anchor to
maintain this same degree of tension on the lateral band. This can be reinforced with additional sutures to the
surrounding periosteum and soft tissue. Any excess lateral band tissue proximally is then excised (Fig. 12-6).
Skin closure is
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per the surgeon's preference, and a protective dorsal splint is applied to maintain the desired position of the
finger.
FIGURE 12-6 Sequence of surgical steps for spiral oblique retinacular ligament reconstruction. (Images courtesy
of James P. Higgins, MD., copyright James P. Higgins, MD.)
Procedures to Correct DIP-Primary Flexible Swan-Neck Deformity

Terminal Tendon Repair, DIP Arthrodesis, and/or Central Slip Tenotomy (Fowler Release) The classic
example of a DIP-primary flexible swan-neck deformity comes from a mallet finger injury that has not healed after
several months either because of neglect or failed healing with either splinting or pinning of the DIP joint. As the
terminal extensor tendon insertion at the base of P3 continues to retract proximally from nonhealing, there is
added extension force at the PIP joint. This combination leads to a flexion deformity at the DIP joint and an
extension deformity at the PIP joint, especially if a patient has a tendency toward PIP hyperextension at baseline.
If the process is caught before a fixed deformity develops, then soft-tissue procedures are an option. If the
terminal tendon is in good enough condition after debridement that the surgeon can reattach it to the base of P3
without excessive tension at the DIP or PIP joint, then this is an option, with reattachment being done via suture
anchors or bone tunnels. After this, the DIP joint is usually pinned in neutral extension for protection of the repair
for 6 weeks. If repair is not an option, then a Fowler central slip tenotomy at the PIP joint is typically preferred,
with or without a procedure to further correct the DIP flexion deformity such as temporary pinning or arthrodesis.
Fowler described two different extensor tendon release procedures, one to correct swan-neck deformities and
one to correct boutonniere deformities. For this reason, surgeons and other healthcare providers should be
careful when discussing Fowler releases or tenotomies so as to avoid confusion between these two procedures.
In the case of swan-neck deformities, Fowler described release of the central slip at its insertion on the base of
P2. For this procedure, the central slip is isolated and gradually released from the dorsal base of P2 until the PIP
hyperextension deformity is corrected. By releasing the central slip, there is less extension force exerted at the
PIP joint so that more can be transferred to the DIP joint via the intrinsic mechanism, provided that there is some
degree of soft-tissue connection between the distal lateral band confluence into the terminal tendon and the
dorsal P3.
For DIP fusion, I prefer to use a distally based dorsal incision at the DIP joint with the transverse portion dorsally
over the DIP extension crease and radial and ulnar midaxial extensions. The skin and subcutaneous tissue are
elevated as a full-thickness flap distally just above the extensor tendon and P3 periosteum. If more exposure of
distal P2 is needed, this can be converted into a full H-shaped exposure by extending the midaxial incisions more
proximally to also create a proximally based dorsal skin flap. The terminal extensor tendon is transected if
present, and the distal P2 and proximal P3 articular cartilage and subchondral bone are removed until there is
healthy cancellous bone at each surface. I prefer to use a rongeur for this and to create a cup-and-cone
configuration where the proximal P3 base is shaped as a cup to accept the rounded distal P2. There are several
bone fixation options available; I use a headless cannulated screw when possible. Appropriate sizes are typically
in sets that are in a range between 2.0 mm and 3.0 mm. I hold one of the screws adjacent to the P3 and obtain
fluoroscopic images to ensure as best as possible that the trailing screw threads will not violate the P3
significantly. I drill the guidewire into the P3 from proximal to distal and check A/P and lateral fluoroscopy for
central placement and then advance through the skin of the fingertip distally. I then take the guidewire out and
reverse it and insert it into the base of P3 again from proximal to distal so the blunt tip of the wire exits the
fingertip. The DIP fusion site is then reduced and the guidewire is driven proximally across the DIP into the base
of P2. Fluoroscopic images are again taken to ensure acceptable placement of the wire in P2 and appropriate
planned DIP fusion position. At this point, I also check clinical fusion position by flexing the wrist to use finger
extensor tenodesis to simulate active finger extension and then simulate active finger flexion by extending the
wrist and applying manual pressure to the forearm finger flexors. Having confirmed good fusion position, a small
incision is made at the exit point of the guidewire at the fingertip, and a hemostat is used to spread down around
the guidewire to the tip of P3. Use of fluoroscopy is invaluable in deciding how deep to insert the screw; I
typically aim to engage the isthmus of P2 proximally and to bury the head just below the tip of P3 distally without
significantly violating the palmar or dorsal cortex, which could jeopardize fixation and disrupt the germinal matrix
of the nail. Using fluoroscopy, I make sure the leading tip of the guidewire is located in the isthmus of P2 where
I'd like the leading tip of the screw to be after insertion and measure the screw length based on this, typically
subtracting a few millimeters from the measured length to allow for compression and for burial of the trailing
thread in the distal P3. Some headless cannulated screw systems use a cannulated drill at this point, and others
simply use a countersink at the distal P3 or nothing. Finally, the screw is inserted over the guidewire while an
assistant holds the DIP fusion site in
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reduction and compression (Fig. 12-7). Fusing the DIP joint may be enough to correct the PIP hyperextension if it
is not severe and the patient was still able to actively initiate PIP flexion without assistance preoperatively. In
these cases, we are trying to prevent worsening of the PIP hyperextension by fusing the DIP joint and typically
protecting the PIP joint postoperatively. If the PIP hyperextension is more severe to the point where the patient is
unable to actively initiate PIP flexion unassisted, then a secondary procedure is performed using any of the soft-
tissue options for PIP-primary flexible swan-neck deformity mentioned earlier.
FIGURE 12-7 DIP arthrodesis in the setting of swan-neck deformity.
Procedures to Correct Fixed Swan-Neck Deformity

Extensor Tenolysis, Joint Capsulectomies, and Soft-Tissue Reconstruction For patients who have fixed
swan-neck deformities but well-maintained articular cartilage and skeletal structures about the involved joints,
the first-line option is hand therapy with progressive splinting or casts to attempt to convert a fixed deformity to a
flexible deformity. This is typically trialed for at least 4 to 6 months before abandoning efforts, unless there is a
compelling reason to do so sooner. If these efforts fail and the patient still has significant functional limitations, a
surgical option is to release the components that are causing the fixed deformity in order to obtain passively
correctable joints. In these cases, the surgeon makes his or her standard dorsal approach to the finger and first
performs an extensor tenolysis. If this is insufficient to correct the fixed deformity, then a dorsal PIP capsulectomy
is performed. Since the lateral bands are scarred dorsal-centrally, it is acceptable to release between the lateral
bands and the central extensor tendon in order to further release the extensor mechanism and to gain access to
the PIP joint. Once this is complete, the surgeon can excise the dorsal-radial and dorsal-ulnar PIP capsule,
keeping the central slip insertion and collateral ligaments intact. A Freer elevator or similar tool can be gently
inserted into the PIP joint to lyse any adhesions there and to also bluntly release the palmar aspect of the PIP
joint. A gentle manipulation in flexion is again performed on the PIP joint. If there is still insufficient release, the
collateral ligaments are gradually released with gentle manipulation performed after each partial release until
flexion is adequate. Once the fixed deformity has been made passively flexible, the surgeon may then perform
one of the previously described soft-tissue reconstructions to maintain correction of the swan-neck deformity.
Small Joint Arthroplasty and Arthrodesis For patients with fixed swan-neck deformity with poor articular
cartilage or contractures that are too severe for releases and soft-tissue reconstructions, small joint arthroplasty
and arthrodesis are the final surgical options short of amputation. These procedures are typically reserved for
patients with severe arthritic changes in the joints or severe contractures that involve the majority of the
structures about the joints, that is, skin, subcutaneous tissue, tendons, ligaments, and joint capsule.
Contractures such as these can occur following burns, severe crushing trauma, destructive infections,
neuromuscular spasticity conditions, and in association with scleroderma, gout, or similar autoimmune
inflammatory disorders. Unfortunately, small joint arthroplasty typically only maintains the same preoperative
range of motion or may provide some marginal improvement. Thus, for fixed swanneck deformities of this type,
the role of small joint arthroplasty is rather limited. Instead, most surgeons consider small joint arthrodesis for
these situations as long as the skin and soft tissue envelope permit. For fixed swan-neck deformities that require
PIP fusion due to articular damage or severe contracture, I prefer a tension band technique using 0.045 smooth
K-wires for the longitudinal component and approximately 26-gauge stainless steel wire for the figure-of-eight
configuration (Fig. 12-8).
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FIGURE 12-8 Pre- and intraoperative images of PIP arthrodesis for fixed swan-neck deformity.
FDS Tenodesis of the PIP Joint, Lateral Band Relocation, and SORL Reconstruction
Patients are placed in a dorsal splint immediately postoperatively. If patient compliance is a concern, a dorsal
blocking pin can be placed in the distal dorsal P1 at the articular margin to prevent PIP extension beyond a
certain degree, typically approximately 30 degrees. At the first outpatient visit, a therapist makes a dorsal
blocking splint for the PIP joint that allows flexion as the patient's pain and soft tissues permit. For the spiral
oblique retinacular ligament (SORL) procedure, the DIP joint is included in the splint in neutral position and is
protected in neutral during range-of-motion exercises. If a pin was used for the DIP joint or to block PIP joint
extension, they are usually removed at 3 to 4 weeks postoperative. At 6 weeks postoperative, if the PIP joint is
stable to gentle extension stressing, the dorsal block splint can be weaned off. At this point, once range of motion
is adequate without any tendency toward deformity recurrence and there is minimal edema and pain, the
therapist can begin progressive strengthening and return to functional activities for the patient.
Extensor Tenolysis, Joint Capsulectomies, and Soft-Tissue Reconstruction

As long as there are no soft-tissue or bone/joint issues that need protection postoperatively, for these
procedures, I allow immediate range of motion as tolerated by the patient. I use a long-acting local anesthetic for
the digital block at the end of the procedure to allow the patient to do ROM as tolerated. For this reason and for
the early formal therapy sessions, I use Nylon sutures for the skin. Our therapists have communicated that doing
so makes them more confident in pursuing aggressive range of motion in the early postoperative period with less
fear of incision dehiscence. I then prefer to use a light gauze dressing for the finger followed by loosely applied
Coban from the fingertip into the hand and locked at the wrist. The Coban is loosely laid on the finger without
any stretching of the Coban during application in order to prevent arterial or venous ischemia. After applying the
Coban, the finger can be gently compressed by the surgeon to mold the Coban without causing excessive
constriction. This helps with immediate edema control and still allows for ROM, which should be confirmed after
dressing application. I am not aware of any confirmed advantages to starting hand therapy any sooner than 3 to
5 days postoperatively, whereas doing so is definitely painful for the patient and therapist and can lead to
bleeding and incision dehiscence. Therapy beyond this point typically progresses as the patient's pain and soft
tissues allow, including splints as needed to prevent PIP hyperextension and to regain the flexion gained in the
operating room.
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DIP Arthrodesis With or Without PIP Hyperextension Procedure
At the first postoperative visit, patients are fitted with an OT-fashioned DIP neutral splint. Whether a secondary
surgical procedure was required for PIP hyperextension or not, I typically splint in the same manner with an
extension of the DIP neutral splint to include a dorsal block to the PIP joint at around 30 degrees of flexion. The
patient is permitted and encouraged to flex the PIP joint in the splint and after 4 to 6 weeks can start extending
the PIP joint approximately 10 degrees per week with the goal of reaching near neutral PIP extension as long as
there is no tendency toward recurrent hyperextension. At 6 weeks post-op, if the DIP fusion is clinically and
radiographically stable, the patient is allowed to wean out of the DIP splint and can start some tip-pinch activities
and increase activities from there as tolerated.
COMPLICATIONS
Of course, the typical possible complications of any surgery can be seen following these procedures such
as infection, pain, stiffness, weakness, recurrence, and unpredictable final function and symptoms. A
potential complication that is particular to surgical attempts to correct swan-neck deformity is inadvertently
converting the finger to a boutonniere deformity. Again, most of the swanneck procedures lead to an
intended flexion contracture of the PIP joint, and surgeons have traditionally thought that, from a functional
standpoint, patients tolerate boutonniere finger deformities better than swan-neck positioning. The main
concern here is the development of a progressive boutonniere deformity with dysfunctional PIP flexion and
DIP hyperextension. The procedures that are most concerning for this development from a pathoanatomic
standpoint are lateral band relocation and Fowler central slip tenotomy. If the lateral band release has to
extend distally into the triangular ligament, then this could lead to progressive palmar translocation of the
lateral bands as the PIP joint buttonholes between them. If the lateral bands are simply released and not
relocated palmarly during the swan-neck procedure, this could theoretically lessen the chance of
developing a boutonniere deformity. Fortunately, however, even if one of the lateral bands is tethered
palmarly during the swan-neck procedure, this tethering should prevent further palmar translocation. This,
along with leaving the other lateral band untethered, should help to prevent a progressive boutonniere. For
the Fowler central slip tenotomy, the gradual and gentle release of the central slip along with keeping the
triangular ligament intact aims to prevent subsequent boutonniere deformity (6).
RESULTS
Smith and Amirfeyz have provided an excellent review of the latest results of procedures for flexible swan-
neck deformities (4). They noted that the authors of a recent retrospective review of patients undergoing
FDS tenodesis with fixation at the A2 pulley level reported that 19 out of 23 of their patients had good or
excellent results. Preoperative hyperextension averaged 33 degrees and patients gained 26 degrees of
functional PIP flexion on average. For these patients, 70% had complete correction at the DIP level while
30% had at least some improvement and no worsening of the DIP flexion deformity (7).
In the report on lateral band relocation by Tonkin et al., the authors reported on 12 patients with 30 flexible
swan-neck deformities with multiple etiologies (8). The average preoperative PIP hyperextension deformity
of 16 degrees corrected to an average flexion contracture of 11 degrees. Their average follow-up period
was nearly 1 year postoperatively, and they reported no recurrences of the swan-neck deformity. deBruin et
al. used the same technique for cerebral palsy patients and noted deterioration in the results after 5 years
(9). This underscores the specialized issues of swanneck deformities in patients with neuromuscular
conditions. Yet another modification of the lateral band relocation technique was recently described by
Sirotakova et al. (1). In this case, the authors released the ulnar lateral band proximally, placed it through
the flexor pulley, and tenodesed it at the P1, which is a combination of some of the techniques described
earlier. They performed this procedure for 43 patients with 101 swan-neck deformities and at nearly 2 years
of average postoperative follow-up noted an average correction of 13 degrees of PIP hyperextension to 13
degrees of flexion contracture and no recurrence of the deformity.
The authors of another recent article reviewed their results of SORL lateral band transfer. At nearly 2 years
of average follow-up, they reported no recurrences of swan-neck deformity. Average PIP hyperextension
was improved from 21 degrees of hyperextension to 24 degrees of average flexion contracture. As with
other procedures and reports, the overall range of motion was not significantly different postoperatively but
was within a more functional range for patients (10). None of these more recent reports on technique
modifications have any clinically significant differences from more historical results. This reinforces the
concept that surgeons can likely perform any of the procedures that address the pathomechanics of the
deformity and can expect reproducible results with little chance for recurrence in the typical patient
population.
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REFERENCES
1. Sirotakova M, Figus A, Jarrett P, et al.: Correction of swan neck deformity in rheumatoid arthritis using a
new lateral extensor band technique. J Hand Surg Eur 33(6): 712-716, 2008.
2. Engles D, Ditsios K, Boyer M: Reconstruction for flexible and fixed swan-neck deformities. In: Strickland J,
Graham T, eds. Master techniques in orthopaedic surgery: the hand. 2nd ed. Baltimore, MD: Lippincott
Williams & Wilkins, 2005: 435-447.
3. Curtis R: Sublimis tenodesis. In: Edmonson A, Crenshaw A, eds. Campbell's operative orthopaedics. 6th
ed. St. Louis, CA: CV Mosby, 1980: 319.
4. Smith G, Amirfeyz R: The flexible swan neck deformity in rheumatoid arthritis. J Hand Surg [Am] 38(7):
1405-1407, 2013.
5. Feldon P, Terrono A, Nalebuff E, et al.: Rheumatoid arthritis and other connective tissue diseases. In:
Wolfe S, Hotchkiss R, Pederson W, et al., eds. Green's operative hand surgery. 6th ed. Philadelphia, PA:
Elsevier Churchill Livingstone, 2011: 2045.
6. Hiwatari R, Kuniyoshi K, Aoki M, et al.: Fractional Fowler tenotomy for chronic mallet finger: a cadaveric
biomechanical study. J Hand Surg [Am] 37(11): 2263-2268, 2012.
7. Brulard C, Sauvage A, Mares O, et al.: Treatment of rheumatoid swan neck deformity by tenodesis of
proximal interphalangeal joint with a half flexor digitorum superficialis tendon. Chir Main 31(3): 118-127,
2012.
8. Tonkin, M, Hughes J, Smith K. Lateral band translocation for swan-neck deformity. J Hand Surg [Am]
17(2): 260-267, 1992.
9. de Bruin M, van Vliet D, Smeulder M, et al.: Long-term results of lateral band translocation for the
correction of swan neck deformity in cerebral palsy. J Pediatr Orthop 30(1): 67-70, 2010.
10. Borisch N, Haubmann P: Littler tenodesis for correction of swan neck deformity in rheumatoid arthritis.
Oper Orthop Traumatol 23(3): 232-240, 2011.
Chapter 13
Correction of Posttraumatic Extensor Tendon Ulnar Subluxation
of the Metacarpophalangeal Joint with a Dynamic Lumbrical
Tendon Transfer
Keith A. Segalman
Beatrice L. Grasu
E. F. Shaw Wilgis
Posttraumatic failure of the sagittal bands (SBs) at the level of the metacarpophalangeal (MCP) joint results in
extensor tendon instability. When the extensor tendon is no longer centered over the MCP joint, there is a
resultant loss of extension of the finger. Legoust first described traumatic extensor tendon instability in 1866.
Paget, Krukenberg, and Marsh provided later descriptions of the condition. The technique described here has
not been previously published.
PHYSICAL EXAMINATION
The SB is the main stabilizer of the extensor digitorum tendon at the level of the metacarpal phalangeal joint. The
SB forms a cylindrical tube surrounding the metacarpal head and the MCP joint (Fig. 13-1). The sagittal fibers
are superficial to the MCP joint capsule, and there
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is no communication between the sagittal fibers and the collateral ligaments. The radial SB is thinner and longer
than are the ulnar fibers. The SB is thicker in the central digits and thinner in the peripheral digits. The greatest
tension in the SB is noted with MCP flexion and radioulnar deviation, with a vast majority of the injuries occurring
on the radial side. Biomechanical studies have shown that greater than 50% of the proximal radial fibers must be
torn to create extensor tendon instability (Fig. 13-2).
The usual mechanism of injury is a blow to the hand with the MCPs flexed, such as a boxing injury. SB injuries
occur when the finger is forced into flexion with the wrist flexed and ulnarly deviated. Rarely,
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an SB injury may be associated with collateral ligament injuries. The patient will usually present with swelling
and tenderness over the SB and limited or deviated extension of the MCP joint. The most telltale finding is a
painful snapping sensation with concomitant ulnar subluxation of the extensor tendon during active MCP flexion
(Fig. 13-3). Rayan and Murray described a provocative test for SB injury: resisted finger extension and attempted
deviation toward the injured SB elicit apprehension and pain.
FIGURE 13-1 Normal anatomy of the MCP joint (A) and the sagittal fibers (B).
FIGURE 13-2 Diagram of a sagittal band injury. (Adapted from Caroll C IV, Moore JR, Weiland AJ: Posttraumatic
ulnar subluxation of the extensor tendons: a reconstructive technique. J Hand Surg Am 12: 227-231, 1987.)
FIGURE 13-3 Clinical photograph showing the subluxation of the extensor tendon.
Two classification systems have been described, but in our opinion, neither fully characterizes the clinical
situation. Ishizuki differentiates ruptures of the SB secondary to superficial tears and deep tears. Rayan and
Murray have described a more treatment-oriented classification system of three
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varieties emphasizing whether the SB is torn or there is subluxation of the tendon. What is most important is the
assessment of the passive motion in the joint and the stability of the contralateral ligaments.
For acute injuries, immobilization with a cast or Orthoplast splint with the MCP joints in extension and the wrist in
neutral is often satisfactory. Rayan and Murray have reported that conservative treatment is most successful
when begun within 3 weeks of the injury, whereas Inoue recommended repair or reconstruction when the patient
is seen more than 2 weeks after the injury. Occasionally, conservative treatment of acute injuries is
unsuccessful, but most patients with SB injuries will present with a chronic condition.
Extensor tendon instability is most common in the middle finger, followed by the small, index, and ring fingers.
Various authors have suggested that the middle finger is most often involved because of the cross-sectional
thickness of the SB, the distal attachment of the extensor hood, or the increased proximal-distal length of the SB.
These authors noted a less well-developed juncture tendinum in the radial two digits and excessive ulnar
deviation of the metacarpal head in the middle finger versus the ulnar two digits. In our experience, the middle
finger is most often involved.
It is imperative to ensure that there is full passive motion in the digit. Radiographs should be obtained to confirm
that there is no underlying fracture or arthritis. There is no role for arthrography or arthroscopy in the treatment of
this condition.
The lumbrical muscle is chosen for reconstruction given its radial location, ease of harvest, and, most
importantly, its synergistic action to stabilize and radialize the extensor tendon. The lumbrical muscle inserts in
the transverse or oblique fibers of the extensor, with half of the fingers having an additional attachment to tendon
or bone (Fig. 13-4). The lumbrical has no role in MCP flexion,
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whereas the interossei are the main flexors of the proximal phalanx. Electromyographic studies have determined
that the lumbrical fires with digital flexion to prevent clawing. Since extensor instability is most pronounced with
MCP flexion, transferring the lumbrical will serve as a direct antagonist to the deforming force of the extensor.
Thus, the lumbrical acts as a dynamic tendon transfer to correct ulnar subluxation of the extensor tendon.
FIGURE 13-4 Normal anatomy of the lumbrical muscle.
SURGERY
Local anesthesia with sedation is the preferred choice, but regional anesthesia is an acceptable alternative. The
patient is positioned supine on the operating room table. An upper arm tourniquet is applied, and the arm is
draped in a standard fashion. After exsanguination of the arm, a dorsal 4-cm incision is centered over the MCP
joint (Fig. 13-5). The pathology is confirmed, and the extensor is reduced over the MCP joint.
Reduction of the extensor typically does not require release of the ulnar sagittal fibers. The lumbrical is
harvested just proximal to its insertion into the oblique fibers and gently mobilized proximally (Fig. 13-6). Care is
taken to avoid detaching the tendon from the muscle belly and
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separating the lumbrical from the interossei. Because the lumbrical and interossei join into one conjoined tendon,
the lumbrical could easily be separated from the muscle belly if the surgeon is not careful.
FIGURE 13-5 Dorsal incision over the MP joint demonstrating ulnar subluxation of the extensor and attenuation
of the radial sagittal fibers.
FIGURE 13-6 Harvesting the lumbrical from just proximal to its tendinous insertion.
FIGURE 13-7 Passage of the tendon transfer through a split in the extensor dorsally.
An isometric point is chosen for passage of the transfer by holding the extensor reduced with a pair of forceps
and gently ranging the finger or asking the patient to gently flex the finger. The tendon of the lumbrical is now
passed through a small longitudinal slit in the extensor at the isometric point (Fig. 13-7). The tension is set by
ranging the finger and ensuring that the extensor does not subluxate ulnarly. If the ulnar sagittal fibers were
released and excess tension was applied to the transfer, then radial subluxation would result. A nonabsorbable
4-0 suture is used to secure the transfer. The wound is closed with nonabsorbable sutures, and the patient is
immobilized in a short splint with the MCP joints in extension and the proximal interphalangeal joints free.
The sutures are removed 8 to 10 days after the surgery, and immobilization is continued for a total of 4 weeks
after surgery. We prefer a short arm cast with the wrist in neutral and the MCP joints in extension. It is important
to leave the proximal interphalangeal joints free. Dynamic extensor splinting is not usually used, but it is a
reasonable alternative. The patient is expected to regain nearly full motion and strength. Active motion is begun
4 weeks after surgery, and strengthening is begun 6 weeks after surgery.
The patient will continue with therapy for approximately 6 to 8 weeks (Fig. 13-8). Minimal loss of motion is
expected from this technique. The patient should be able to return to normal activities within 3 months. In our
experience, there has never been a recurrence.
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FIGURE 13-8 Intraoperative photograph (A) and postoperative photographs after lumbrical transfer for extensor
tendon instability. Postoperative dorsal view (B), active extension (C), and active flexion and centralization of the
tendon (D) are shown.
RESULTS
Stiffness is rarely a problem after the procedure, as the joint capsule is not violated. In our experience,
patients have averaged 90 degrees of MCP motion. We have not seen any recurrence of the deformity, and
all patients have been satisfied with the procedure. No interphalangeal stiffness has been identified.
COMPLICATIONS
The complication rate is very low. Superficial infection has only occurred in one patient, and this was
successfully treated with oral antibiotics without the need for further surgery. No deep infection has been
identified, and we feel that there is no indication to routinely use preoperative antibiotics.
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As noted above, the surgeon should expect minimal stiffness after the surgery. Radial deviation has not
been seen and would not occur with normal bony architecture. There has not been any need for secondary
surgery, and all patients were satisfied with the procedure. In theory, a failure could result in recurrent
subluxation after removal of the cast. If recurrence occurred, we would prefer the technique described by
Carroll et al.
CONCLUSIONS
A lumbrical muscle transfer provides excellent correction for SB ruptures of the extensor located over the
MCP joint. The lumbrical is a dynamic transfer easily harvested, which minimizes stiffness. Complications
are few, and recurrence has not been observed in our series of patients.
RECOMMENDED READING
Carroll C, Moore JR, Weiland AJ: Posttraumatic ulnar subluxation of the extensor tendons: a reconstructive
technique. J Hand Surg Am 12: 227-231, 1987.
ElMaraghy AW, Pennings A: Metacarpophalangeal joint extensor tendon subluxation: a reconstructive

stabilization technique. J Hand Surg Am 38: 578-582, 2013.
Inoue G, Tamura Y: Dislocation of the extensor tendons over the metacarpophalangeal joints. J Hand Surg
Am 21: 464-469, 1996.
Murray D, Rayan GM: Late reconstruction of sagittal band laceration. Orthop Rev 23: 445-447, 1994.
Rayan GM, Murray D: Classification and treatment of closed sagittal band injuries. J Hand Surg Am 19: 590-
594, 1994.
Ritts GD, Wood MB, Engber WD: Nonoperative treatment of traumatic dislocations of the extensor digitorum
tendons in patients without rheumatoid disorders. J Hand Surg Am 10: 714-716, 1985.
Saldana MJ, McGuire RA: Chronic painful subluxation of the metacarpal phalangeal joint extensor tendons. J
Hand Surg Am 11: 420-423, 1986.
Smith RJ: Intrinsic muscles of the fingers: function, dysfunction, and surgical reconstruction. In: AAOS
instructional course lectures. Vol. 24. St. Louis, CA: Mosby, 200-220, 1975.
Watson HK, Weinzweig J, Guidera PM: Sagittal band reconstruction. J Hand Surg Am 22: 452-456, 1997.
Chapter 14
Zone 1 Flexor Tendon Injuries
Blaine Todd Bafus
Eugene Y. Tsai
Catherine Szado
OVERVIEW
Acute zone I flexor tendon injuries are a commonly encountered condition caused by either an avulsion of the
flexor digitorum profundus (FDP) tendon from its insertion on the distal phalanx of the finger (the so-called jersey
finger) or a laceration of the FDP tendon distal to the insertion of the flexor digitorum superficialis (FDS) tendon.
A frequently used classification system for these types of injuries was introduced by Leddy and Packer (1) in
1977 with a modification added by Trumble et al. (2) in 1992. This classification system aids the surgeon in
choosing timing of and appropriate treatment for these injuries. Type I injuries occur when the FDP tendon
avulses and retracts into the palm, thus disrupting the entire blood supply and nutritional support of the tendon.
The viability of the tendon is jeopardized, and repair must occur within 7 to 10 days of injury. Type II injuries
occur when the tendon retracts to the level of the proximal interphalangeal (PIP) joint, which likely signifies some
remaining blood supply via the long vinculum and diffusion of nutrients through the synovial fluid. Delayed repair
up to 6 weeks postinjury can be attempted with success (however, the goal should be repair as soon as
possible). Type III injuries occur when the tendon only retracts to the level of the A4 pulley typically because the
FDP tendon avulses a piece of bone, which prevents further retraction. Both vinculae remain intact and tendon
viability is preserved affording delayed repair. Type IV injuries occur when the FDP tendon detaches and retracts
from the bony avulsion fragment and viability of the tendon is unpredictable. Differentiating between type III and
IV injuries can be challenging, and when physical exam findings are inconclusive, further imaging may be
required. While all of these injuries occur outside of the proverbial “no man's land,” they still pose significant
challenges, which include localizing the tendon and passing it through the annular pulleys of the retinacular
sheath, achieving robust healing between tendon and bone, as well as avoiding the “quadrigia” effect, which can
occur when the tendon is shortened greater than 1 cm. This shortening places increased tension on the
remaining tendons of the FDP muscle with resultant diminished flexion of the remaining digits or “quadrigia.” We
will limit our discussion in this chapter to the repair of acute zone I tendon injuries.
CLINICAL PRESENTATION
Patients classically present with a history of a forced extension injury to an actively flexed digit or a laceration
sustained to the volar surface of the digit distal to the insertion of FDS. On physical exam, the normal cascade of
the fingers will be disrupted with the affected finger held in a more extended posture. The patient will be unable
to actively flex the distal interphalangeal (DIP) joint, most easily tested by holding the metacarpophalangeal
(MCP) and PIP joints of the digit in full extension. Sometimes, an avulsed bony fragment may be palpated along
the digit. A thorough examination of the entire hand and forearm should be performed to identify any other
concomitant injuries. The point of maximum tenderness along the injured digit or proximally in the palm is often
an indication of where the proximal avulsed tendon end resides. Radiographs may demonstrate the location of
an avulsed bony fragment or any other bony injury. When the diagnosis remains elusive, ultrasound
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(US) or magnetic resonance imaging (MRI) may be appropriate. These additional imaging modalities can also aid
in identifying the location of the proximal FDP tendon stump, which in a delayed presentation may alter the
treatment course.
The restoration of function to a digit that has sustained a flexor tendon injury can be a long and tedious road.
Considerable time should be devoted to counseling the patient regarding the nature of the injury as well as the
possible need for secondary operations and the extensive postoperative rehabilitation required to achieve a
desirable outcome.
INDICATIONS
Most zone 1 tendon injuries should be considered for prompt surgical repair unless prohibited by medical or
social factors. The above mentioned classification system is helpful in determining the timing of intervention
and appropriate care. Delayed presentation of type I and II injuries is oftentimes better managed with
nonoperative care or DIP joint arthrodesis. Two-stage tendon reconstruction of zone I injuries requires
passing a tendon graft through an intact FDS insertion with potential adhesions and suboptimal functional
results. Patients presenting with suspected type III/IV injuries in a delayed fashion must also be counseled
that intraoperative findings of more proximal tendon retraction either secondary to tendon avulsion off the
bony fragment or inaccurate initial diagnosis may preclude primary repair.
CONTRAINDICATIONS
Active infection
Wound contamination
Significant skin loss over the flexor tendon
Multiple severe injuries to the hand and fingers
For some patients, a primary DIP fusion may be a reasonable alternative.
As stated above, a thorough physical examination will most oftentimes determine the extent of injury. The
surgeon must note the normal resting finger cascade, location, and extent of any wounds; document individual
tendon function of the FDS and FDP; and assess digital nerve function and vascular integrity of the digit. We
also carefully palpate along the flexor sheath and palm evaluating for the point of maximum tenderness. This
point most often corresponds with the location of the retracted tendon end. Radiographic examination of digit and
hand evaluates for avulsion fractures of distal phalanx volar rim and associated bony injuries. More advanced
imaging (MRI/US) is utilized at the surgeon's discretion and is individualized by each case and unique
presentation.
TECHNIQUE
Either regional or general anesthesia is utilized per surgeon and anesthesiologist choice. Wide awake surgery is
gaining popularity for these injuries but has yet to be utilized at our institution and is discussed in detail
elsewhere in this book. The patient is placed supine on the operating table with the arm abducted 90 degrees at
the shoulder and a well-padded tourniquet is applied. Preoperative antibiotics are administered within 1 hour of
skin incision. The surgical “time-out” is completed. The “time-out” is an opportunity to confirm that all special
equipment is available including tendon graspers, pediatric feeding tube, handheld power/wire driver, micro
instruments, and fracture fixation set when indicated and sheath dilator (we routinely use the Toby Orthopaedic
disposable device). The suture of choice is individualized, but we prefer for an end-to-end repair to use 4-0
looped Supramid Extra LCW on a 3/8 inch taper needle or 4-0 Ethibond suture on an RB1 taper needle. For a
tendon to bone repair, we use a 3-0 Ethibond suture and two Keith needles. Alternatively, micro-sized suture
anchors of choice may be utilized. The arm is exsanguinated, and the tourniquet is inflated to 100 mm Hg above
the patient's systolic blood pressure. The surgical approach can vary between a Brunner style and midaxial
incision along the digit with extension proximally into the palm as needed. Generally, we prefer an oblique
incision over the distal phalanx with a midaxial extension toward the MP flexion crease if a proximal extension is
anticipated (Fig. 14-1). The incision should be favored to the side of a concomitant digital nerve injury when
present. T-shaped extensions of transverse lacerations should be avoided but may be dictated by the situation.
A window in the flexor sheath may be required for repairs between A2 and A4. We have
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released part of or all of the A4 pulley to accommodate the repair without any noted complications. Alternatively,
if the DIP joint was flexed at the time of injury, the distal stump may be accessed by opening the C3-A5 complex.
Tendon retrieval can be difficult, and proper technique at this stage will impact overall outcome. The extent of
proximal retraction determines the technique utilized. When the tendon end is visible, it may be retrieved by
gently grasping with a tendon grasper or hooked with a single prong skin hook. Repeated blind grasps into the
flexor sheath should be avoided. Alternatively, some have had success milking the tendon from proximal to distal.
For a tendon that has withdrawn proximally into the sheath or palm, a proximal midpalmar incision may be used
as a window to obtain the tendon (Fig. 14-2). If it is still within the sheath, a retrograde feeding catheter (#5
pediatric feeding tube) may be passed retrograde down the flexor sheath and sutured to the tendon proximal to
the A1 pulley. This will preserve the FDP and FDS relationship within the chiasm. The catheter is then pulled
distally, which easily delivers the tendon stump into the distal repair site. A transversely oriented 25-gauge
needle then secures the tendon for repair, and the connecting suture is severed within the palm and the catheter
is withdrawn. Similarly, the FDP tendon that has withdrawn completely into the palm may have a suture placed
within the stump and be drawn distally using a tendon grasper.
End-to-end tendon repair requires a distal tendon stump of sufficient length—at least 0.75 cm. We prefer a
locked cruciate 8 strand repair utilizing the looped Supramid suture (Fig. 14-3). We supplement our repair with a
volar epitendinous stitch using a running locking 6-0 nylon suture.
Direct tendon to bone repair is the more common scenario (Fig. 14-4). A 3-0 Ethibond suture is placed into the
tendon stump utilizing a Bunnell style technique crossing 3 times and coming out distally. The insertion site is
freshened up to bone with a small rongeur. There is no need to create a bone trough on the volar cortex. Keith
needles are advanced through the distal phalanx at the FDP insertion site from volar to dorsal, exiting proximal to
the germinal matrix (Fig. 14-4A). We utilize a wire driver to place our Keith needles and confirm position with
intraoperative imaging. A small nick in the dorsal skin is made, and the sutures are tied over the bone and
extensor tendon (Fig. 14-4B, C). Digital nerve and vessel repairs are performed at this time when indicated.
FIGURE 14-1 An oblique incision is made over the distal phalanx.

FIGURE 14-2 A proximal midpalmar incision may be used to obtain the FDP tendon.
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FIGURE 14-3 Locked cruciate suture technique. (From Berger RA, Weiss A-PC: Hand surgery. Philadelphia, PA:
FIGURE 14-4 A-C: Two Keith needles are advanced through the distal phalanx from volar to dorsal proximal to
the germinal matrix.
Prior to skin closure, repair integrity and appropriate tendon gliding are confirmed. I prefer to let down the
tourniquet at this time and achieve meticulous hemostasis. Diminishing postoperative hematoma, swelling, and
pain encourage and enhance our early motion therapy protocol. Skin closure is at surgeon's discretion. A well-
padded dorsal blocking splint is applied with the wrist in 20 degrees of flexion, MP joints flexed, and IP joint
extended. We include all digits (excluding the thumb) in our dressing. Instructions pertaining to strict elevation
and the importance of maintaining the postoperative dressing are stressed prior to patient discharge.
PEARLS AND PITFALLS
The proper relationship of the FDP and FDS must be re-established.
The FDP passes through the slips of the FDS and palmar to Camper's chiasm.
The FDP should not be advanced more than 1 cm, or “quadregia” may result.
Repair the tendons prior to any microsurgical procedures.
The Toby instrumentation is helpful for passing an edematous tendon through a pulley.
Avulsion fragments too small to accept a screw are excised and the tendon repaired to the distal phalanx as
outlined.
Take care to not bring the Keith needles up through the germinal matrix.
The knot may become symptomatic after the tendon has healed requiring removal. This can be done using a
scalpel and digital block in clinic at least 6 weeks after tendon repair.
The all-inside technique avoids the complications associated with an external button and the costs associated
with suture anchors.
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The challenging goal is for tendons to heal without rupture or gap and to glide freely with minimum adherence to
the surrounding structures, thus maximizing functional outcomes. At our institution, we have adapted components
of the Duran, Kleinert, and Indiana Tenodesis programs. We also incorporate the “Pyramid of progressive force
exercises” as outlined by Groth (3). Key components include controlled passive range of motion (PROM) and
gentle active flexion combined with synergistic wrist extension. Each therapy program is individualized and
considers adhesion formation, edema, severity of injury, delay in repair, and quality/type of repair. Additionally,
the patient's medical comorbidities, smoking and substance abuse, and socioeconomic factors will all influence
the rehabilitation protocol.
Phase 1 (3 days to 3 weeks postoperative):
The patient is educated on compliance, signs of infection, precautions, edema control, and scar massage.
Splint: custom dorsal blocking splint with the wrist in neutral, MCPs at 50 to 60 degrees, and IPs in full
extension. We typically do not add more flexion for concomitant digital nerve repairs. If patient compliance is
a concern, the operative dressing may initially be debulked, and the patient begins a controlled mobilization
program with the operative splint intact. This allows the therapist time to establish a rapport with the patient.
Careful monitoring of PIP and DIP flexion contractures is vital.
Rubber band traction: despite the decreased popularity of Kleinert's dynamic traction program, we have
found that in certain patients, this program promotes compliance. To prevent PIP flexion contractures,
rubber bands are removed at night and a Velcro strap is applied to hold the PIP joints in extension.
Exercises: with splint on, modified Duran exercises are initiated including isolated passive DIP motion and
isolated PIP motion. Passive composite finger extension with MCP flexion is also incorporated. For
compliant patients with a strong repair, active place and hold exercises are initiated on the first
postoperative visit after warming up with the modified Duran passive exercises. We also start tenodesis
exercises at this time. The splint is removed for active place and hold exercises, which allows for the wrist to
extend 20 to 30 degrees. If the patient is noncompliant, place and hold exercises and tenodesis exercises
are done only in therapy.
Frequency and vigor of exercises depends on edema, stiffness, pain, and adhesion formation. If adhesions
are significantly limiting tendon gliding, treatment is progressed in accordance with the previously
mentioned pyramid of progression. Conversely, if the tendon is gliding freely, the patient is protected longer.
Phase 2 (3 to 6 weeks postoperative):
Splint: begin weaning out of the splint, which may include modifying to a hand-based splint, buddy tape for
protection, and PIP extension splinting if indicated.
Precautions: non-weight bearing with fingers and wrist extended. No forceful grasping. Use of hand for light
ADLs only.
Exercises: evaluate for adhesions and active flexor lag. Begin active place and hold and tenodesis
exercises if not previously started. Initiate tendon glides (active composite fist, hook, straight fist, and
isolated FDS gliding). Blocking exercises to the DIP and PIP are initiated with careful instruction not to
overly strain against the blocking mechanism. Blocking exercises to the DIP and PIP are started toward the
end of phase 2; however, early blocking exercises are not initiated in FDP repairs of the small finger.
Phase 3 (6 to 12 weeks postoperative):
Monitor for adhesion and active flexor lag, advance as appropriate.

Progress to light strengthening with putty and sponge.
Resisted tendon gliding and blocking are not started until 8 weeks postoperatively.
Return to work/unrestricted ADLs averages 10 to 12 weeks postoperatively.
Pearls and Pitfalls:
The postoperative program must be individualized and requires an experienced hand therapist.
If adhesions and joint stiffness are limiting tendon gliding, treatment is progressed. Conversely, if the tendon
is gliding freely, the patient is protected longer.
Communication between the therapist and surgeon is critical.
Patient compliance and motivation will greatly influence functional outcomes.
COMPLICATIONS
Rupture of a flexor tendon repair is a significant complication. It may occur during therapy, with inadvertent
strong gripping or lifting, or while the patient is sleeping. Using modern techniques, good early range of
motion may breed overconfidence in the strength of the healing tendon.
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Once a rupture is suspected, the preferred treatment is prompt exploration and repair. In the case of a zone
1 rerupture, the patient may opt for a DIP fusion rather than a staged reconstruction if the tendon is no
longer directly repairable.
The most frequent late complication following early postoperative mobilization programs is the development
of flexion contractures at the PIP or DIP joints or both. Prompt recognition of the development of
contractures, modification of the motion program to permit greater extension, and the judicious use of
dynamic splints can help to prevent or overcome these deformities before they progress too far.
Alternatively, tendon adhesions may form and prohibit sufficient gliding of the tendon to allow for adequate
digital function. After several months, if no appreciable improvement in motion despite vigorous therapy
occurs, a tenolysis procedure may be considered. This should only be performed after the tissues have
reached “equilibrium” with soft pliable skin and subcutaneous tissues and minimal reaction around the
scars. Joint contractures must be mobilized and a normal or near-normal PROM achieved prior to
considering tenolysis.
RESULTS
We have been using the all-inside zone 1 repair at our busy urban trauma center for several years. A recent
attempt to perform a retrospective analysis on the clinical results of the technique at our institution was
stifled by the unexpectedly poor follow-up of this injury in our population. Anecdotally, this technique in our
hands has not been associated with an increased rate of failure over the button technique and avoids the
risks associated with an external device in our population (Fig. 14-5). The technique was recently evaluated
in a cadaveric study by Chu et al. (4) and found to be comparable to the other available surgical repairs.
FIGURE 14-5 A-C: Clinical photographs following repair of a zone I flexor tendon injury.
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ACKNOWLEDGMENT
The authors would like to thank Dr. Kevin Malone for the use of his clinical images.
REFERENCES
1. Leddy JP, Packer JW: Avulsion of the profundus tendon insertion in athletes. J Hand Surg [Am] 2: 66-69,
1977.
2. Trumble TE, Vedder TE, Benirschke SK: Misleading fractures after profundus tendon avulsions: a report
of 6 cases. J Hand Surg [Am] 17: 902-906, 1992.
3. Groth GN: Pyramid of progressive force exercises following flexor tendon repair. J Hand Ther 17: 31-42,
2004.
4. Chu J, Chen T, Awad H, et al.: Comparison of an all-inside suture technique with traditional pull-out suture
and suture anchor repair techniques for flexor digitorum profundus attachment to bone. J Hand Surg [Am]
38A: 1084-1090, 2013.
Chapter 15
Zone II Flexor Tendon Repair
David B. Shapiro
Nathan A. Monaco
In flexor tendon parlance, the region between the distal palmar crease and the FDS insertion has been described
in many ways, from Bunnell's initial description as “no man's land” (1) to McCash's more descriptive “deathbed of
many a stout profundus” (2,3) to Verdan's present-day “zone II” (4) (Fig. 15-1). It is the area where the flexor
digitorum superficialis (FDS) and flexor digitorum profundus (FDP) change position relative to one another within
the confines of the fibroosseous digital sheath. Based on previous attempts at repair, Bunnell stated that tendons
lacerated at this level “cannot [be joined] by suture with success… It is better to remove the tendons from the
finger and graft in a new tendon” (1). Although some advocated primary repair as early as 1940 (including
Bunnell, in certain circumstances), a long tradition of excision and grafting limited enthusiasm for tendon repair
(6). Verdan's promising early results (7) began to usher in a new era in tendon repair. Kleinert et al. (8)
presented their 10-year experience in zone II tendon repairs, rehabilitated with an early, protected motion
program, set the stage for the progressive advances in tendon repair that followed. Advancements in our
knowledge of tendon biology and suture characteristics, the routine use of loupe magnification, more refined
operative repair techniques, and better postoperative rehabilitation protocols have led to the establishment of
primary tendon repair as the current standard of care for zone II flexor tendon lacerations (9).
At present, the goals of flexor tendon repair include precise approximation of the tendon ends to promote intrinsic
tendon healing, creation of a repair site with sufficient strength to limit gap development during the entire
recovery process, and development and execution of a rehabilitation protocol to limit tendon adhesion and
maximize digital motion without causing rupture of the repaired tendon. Obtaining consistent, excellent results in
these injuries remains challenging for surgeons, patients, and therapists alike.
ANATOMY
Digital flexion is provided by two tendinous extensions of the extrinsic forearm muscles, the FDS and FDP. The
flexor pollicis longus tendon provides extrinsic thumb flexion. The FDP has one common muscle belly (often with
a separate radial bundle directed toward the index finger) originating on the anterior-medial ulna and
interosseous membrane, which sends individual tendons to insert on the distal phalanx of each finger. Lumbrical
muscles originate from the four FDP tendons in the palm, with their own tendons joining the interosseous tendon
and forming the radial lateral band. The FDS originates from multiple points on the distal humerus, ulna, and
radius. In the midforearm, it divides into four distinct muscle bellies, with a superficial layer to the long and ring
fingers, and a deeper layer to the index and small fingers. The FDS tendons lie superficial to the FDP in the
palm, dividing, rotating, and inserting over the proximal third of the middle phalanx, with interconnections
between the two FDS slips at Camper's chiasm, over the PIP joint (10) (Fig. 15-2). While independent FDS
function to the small finger is often absent, the tendon itself is almost always present (12).
The fibrous retinacular sheath, or pulley system, consists of five annular and three cruciate condensations (also
shown in Fig. 15-2). The sheath begins at the metacarpal neck and ends at the distal phalanx, although
tenosynovial extensions to the wrist occur in the thumb and small finger (the radial and ulnar bursae). The
sheath and synovial system function to maintain a
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smooth gliding system for the tendons, to provide nutrition and lubrication, and, at the level of the pulleys, to
keep the tendons close to the axis of joint rotation, increasing mechanical efficiency and preventing bowstringing.
Intrinsic blood supply to the flexor tendons occurs through the vincula (Fig. 15-3), with relatively avascular areas
beneath the A2 and A4 pulleys.
FIGURE 15-1 Flexor tendon zones I through V. Zone I is distal to the FDS insertion, zone II between the FDS
insertion and beginning of A1, zone III in the palm, zone IV under the transverse carpal ligament, and zone V
proximal (Verdan C: Primary repair of flexor tendons. J Bone Joint Surg Am 42(A): 647-657, 1960, Ref. 5).
FIGURE 15-2 Flexor tendon pulley system. The annular pulleys are designated A1 through A5, with cruciate
pulleys C1, C2, and C3. This specimen has a relatively thin A4. Tang's subdivision of Zone II includes 2A which
covers the long insertion of the FDS; 2B extending from the proximal edge of 2A to the distal edge of the A2
pulley; 2C covering the length of the A2 pulley; and 2D which is proximal to A2. (Tang JB. Flexor tendon repair in
zone 2C. J Hand Surg Br 19(1): 72-75, 1994.) The actual repair can traverse more than one subdivision as the
digit moves. Note how the FDS tightly encircles the FDP (held in the retractor) beneath and distal to the A2
pulley.
Kleinert and Verdan described five flexor tendon zones on the palmar aspect of the hand, based on anatomic
differences and healing potential (Fig. 15-1) (4,5). Zone II spans from the proximal aspect of the A1 pulley to the
insertion of the FDS on the middle phalanx and can be further divided into subzone A through D (11) (Fig. 15-2).
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FIGURE 15-3 Vincula—Note the location of the vincula, which provide a vascular supply to the tendons to aid in
intrinsic tendon healing. The FDS tendon divides to allow the FDP to pass through, with tendinous
interconnections at Camper's chiasm. VB, vincula brevis; VL, vincula longus; CC, Camper's chiasm.
INDICATIONS
With rare exception, complete zone II flexor tendon lacerations require surgical intervention. It is important to
ascertain when the injury occurred, the mechanism, and (if possible) the position of the hand at the time of
injury. Saw injuries, or those with a crushing component, for example, can cause tearing of tendon edges,
leading to different challenges in repair and rehabilitation when compared to the clean tendon transections
seen after sharp knife lacerations (13). Injuries that occur when the hand is closed will result in tendon
lacerations well distal to the skin laceration.
When examining the patient, make note of the location and degree of wound contamination to aid in
planning incision extensions and to determine whether delaying repair will risk deep infection.
Neurovascular examination should be performed to assess the integrity of the digital nerves. If both nerves
are believed to be transected, more urgent exploration may be warranted if arterial repair is anticipated. The
tendon laceration will often lead to an alteration of the normal resting digital cascade (Fig. 15-6A). Deep
flexor tendon function is assessed by testing active flexion of the DIP joints. FDS function is tested by
examining independent PIP flexion while the other digits are held extended (Fig. 15-4). X-rays are warranted
to rule out any fractures or foreign bodies.
Emergent primary repair of complete zone II flexor tendon injuries is necessary only in cases with gross
contamination or vascular injury requiring repair. Isolated tendon repairs are technically easier to do sooner
rather than later, but a 1-week (or even 2-week) delay seldom changes the difficulty or outcome. While
surgical repair should be performed expediently, it is appropriate to delay until there is a full, well-rested
surgical staff, appropriate assistance, and time to do a meticulous repair of all the injured structures. As time
passes, edema of the tendon ends, muscle shortening, and scar in the sheath make tendon approximation
and passage of the tendon under the pulleys more difficult.
FIGURE 15-4 A: Testing of the FDP is done by asking the patient to demonstrate active DIP flexion while
the examiner holds the PIP extended and allows flexion of the other fingers. B: Testing of FDS by holding
the others digits extended at the PIP and DIP joints and asking the patient to flex the injured digit.
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The most important step in preoperative preparation is a frank discussion with the patient regarding the
implications of the injury, the anticipated outcomes, the importance of compliance in the therapy programs,
and the required activity restriction. The patient should understand that unrestricted activity will need to be
avoided for 3 months following surgical repair, that few patients will regain perfect motion, and that a few
will require reoperation for rupture of the repair or stiffness.
CONTRAINDICATIONS
Active infection and gross wound contamination: These may require debridement and a short delay in primary
tendon repair.
Delayed presentation: Presentation after a couple weeks will likely make primary repair more difficult. Exploration
is still warranted, with primary repair of at least the FDP if possible (partial or total FDS excision may be required
to pass the FDP through the pulleys). The surgeon must be prepared for an alternative procedure if primary
repair without undue tension cannot be performed—either tendon grafting or placement of a silicone tendon rod
as the beginning of a two-stage tendon reconstruction.
Delayed presentation of an FDP laceration with intact FDS and good active PIP motion: Repair in this case
risks damaging a functioning FDS in a case where, after exploration, primary repair may still not be possible.
Tendon grafting or silicone rod placement should generally not be performed. A tenodesis of the FDP stump into
the middle phalanx or A4 pulley can be performed in patients with passive DIP hyperextension.
OPERATIVE TECHNIQUE
In this series, clinical and cadaver lab images are used to illustrate the points in the text.
The patient is brought to the operating room after the administration of a prophylactic antibiotic. Regional
anesthesia combined with intravenous sedation or general anesthesia is preferred, as involuntary, uncontrolled
flexion of the fingers at the completion of the procedure will be prevented by the block. The arm is prepped and
draped in a standard fashion, with the sterile field extending above the elbow. With the patient in the supine
position and the surgeon seated in the axilla, the arm is exsanguinated and an upper arm tourniquet inflated to
100 mm Hg of mercury above systolic pressure (less for small arms).
The initial laceration can be explored but will almost always require extension proximally and distally, with
incisions either obliquely or along the midlateral line (Figs. 15-5 and 15-6B).
FIGURE 15-5 The traumatic laceration (red) will almost always need extension, by zigzag incisions (blue),
midlateral extensions (yellow), or a combination. Midlateral incisions keep scar off the tendon repair and provide
better proximal and distal access for any nerve lacerations. Zigzag flaps offer better exposure of the tendon.
Keep flaps full thickness to prevent ischemia at the incision apices, identifying and protecting the neurovascular
bundles.
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FIGURE 15-6 Surgery. A: Resting digital cascade after laceration of both tendons. B: Zigzag incision extension,
with mark for possible palmar incision. C: Tendon ends distal to laceration. 1. FDP; 2. FDS; 3. laceration in volar
plate; 4. distal edge of A2 with empty sheath. D: Becker repair in a slip of the FDS in zone IIB: Note that the
suture knot is left outside of the repair in this small tendon, distal and to the side away from the FDP repair. A 4-0
or 5-0 Prolene is used and will easily slide to aid in tendon approximation. E,F: Initial and final stages of “back-
side-first” epitendinous repair.
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FIGURE 15-6 (Continued ) G: The core suture is being placed, and the loops are left long on the left side of the
tendon. Once tightened, the repair will not slide. H: The core suture has been tied. I: Completion of the
epitendinous repair. J: Normal resting posture. K: Dressings applied.
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Midlateral incisions leave less scar over the tendons, but zigzag incisions may provide better exposure. Skin
flaps are raised, identifying and protecting both neurovascular bundles. If nerve repair is required, the nerve and
vessel are dissected free to allow for neurorrhaphy after the tendon repair.
The laceration in the tendon sheath is identified. The sheath can be opened along either side, proximal to A2 (A1
can be divided if necessary), between A2 and A4 (dividing A3 and the cruciate pulleys), or distal to A4,
depending on the location of the injury. The tendon ends are seldom seen near the sheath opening. If the finger
was flexed at the time of the injury, the distal ends will be well distal to the zone of injury when the digit is
extended (Fig. 15-6C). The proximal ends may retract several centimeters, although FDP retraction is partially
limited by the lumbrical attachments.
Tendon retrieval distally can be done by flexing the digit. If less than a centimeter of the FDP tendons is
exposed, either open (“vent”) or remove the proximal half of A4. While it may be possible to withdraw the tendon
distal to A4, place a suture, and pass the tendon back beneath the pulley, this limits the suture technique options
and makes the epitendinous suture more difficult. Venting or even complete release of A4 is preferred to a weak
repair or one that will not pass under the pulley (14).
Proximal tendon retrieval can often be done by “milking” the palm distally, with the wrist and MP joint flexed. If
unsuccessful, retrieval can occasionally be done using a tendon retriever, and often the two tendons will
advance together. Alternatively, a skin hook can be passed down the tendon sheath past the tendon end, turned
to engage the tendon, and then gently withdrawn to advance the tendons. Repeated attempts are unwarranted,
and if unsuccessful after one or two tries, an oblique incision over A1 will expose the tendons and allow them to
be advanced distally without removal from the sheath. It may be possible to gently pass one of the tendons
distally enough to be grasped and brought into the pulley window. The other tendon will usually easily follow.
Handle the epitendinous surface as little as possible to discourage future scarring. This process can be aided by
passage of a pediatric feeding tube through the pulley into the distal palm. The tendons can be temporarily tied
to this and advanced distally. If the tendon cannot be passed under A2 (or A4 in a zone I repair) without
“mushrooming,” the sheath of a spinal needle can be modified as seen in Figure 15-7. This can then be used as
a “shoehorn” to pass the tendon into the pulley (Gary Kuzma, MD, personal communication). Take care not to
rotate the tendons or disrupt their relative positions. Once the proximal tendons are delivered a centimeter into
the sheath opening, they can be secured with a 25-g needle placed through the tendons and the A2 pulley.
In the distal part of zone II (subdivisions IIa and IIb), the FDS tendon is deep to the FDP and is repaired first. If a
single slip is intact, the other one can be excised or repaired. Repair can be done with a 4-0 or 5-0
nonabsorbable polypropylene (Prolene, Ethicon, Bridgewater, NJ) Kessler or Becker suture (Fig. 15-6D).
Proximal to Camper's chiasm (zone IIc and IId), FDS can be excised or repaired. More proximally, the repair can
be done using a core suture similar to the FDP, as described below.
In this case, FDP repair is initiated using a “back-side-first” technique. A 6-0 Prolene suture is placed in a simple,
running, epitendinous fashion, beginning at the far side of the tendon (Fig. 15-6E, F). Leave a long tail to tie to
later. The sutures should be placed about 2 mm from the cut end and engage about 1 to 2 mm of the thickness
of the tendon. Four or five passes should cover the width of the tendon. The knot is buried on the far side and
not tied on the near side. This allows approximation
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of the tendon ends, improves alignment prior to placement of the core suture, and is much easier to do prior to
placement of the core stitch. In addition to “tidying” the repair, this suture can increase the strength of the repair
between 10% and 50%.
FIGURE 15-7 Use of a modified spinal needle sheath to create a “shoehorn” to pass the tendon through a
pulley. (Courtesy of Gary Kuzma, MD.)
A core suture is placed next. We prefer a 4-strand locking cruciate nonabsorbable suture (e.g., polyethylene
[FiberWire, Arthrex, Naples, FL] or polyester [TiCron, Covidien, New Haven, CT, or Ethibond, Ethicon,
Bridgewater, NJ]) (15). The thin, tapered needle is partially straightened to aid in longitudinal passage through
the tendon. The suture is placed in the center of the tendon (central or in the palmar half), exiting 8 to 10 mm
from the laceration. The locking stitch is done, and the suture passed down the side of the tendon, across the
laceration, and up the side of the other end of the tendon. The locking stitch is placed and the suture brought out
through the laceration at the midpoint of the tendon, but the locking loops are left long (Fig. 15-6G). The tendon
ends are approximated, and the loops tightened. (This suture will not slide—if there is a gap after this step, start
over.) The remainder of the suture can now be placed, with locking loops on both sides of the repair, ending in
the middle of the tendon. The suture is tied, making sure to keep the ends approximated, but not over tightening
and “bunching” the tendon (Fig. 15-6H). Four square throws with polyester and six with FiberWire are adequate
(16).
Finally, complete the epitendinous suture around the volar side of the tendon, placing the core suture knot and
tails within the repair. The suture can be tied to the long tail left when the epitendinous suture was started (Fig.
15-6I).
Note the now normal resting posture of the hand (Fig. 15-6J). Fully flex and extend the digit to make sure the
tendon repairs pass under the pulley. Make sure there is no gapping of the repair after a few cycles of passive
flexion and extension. (Be sure to remove the 25-g needle placed earlier before doing this!) Following irrigation
(and nerve repair if necessary), lay the tendon sheath over the repair and close the skin with interrupted nylon
sutures. Use 5-0 fast-absorbing plain gut (Ethicon, Bridgewater, NJ) in children.
Place a bulky dressing in the palm (don't wrap the fingers, as the dressings will be much more difficult to
remove), and place a palmar short arm splint with the wrist in neutral. Place a dorsal forearm-based splint over
this, with the MCP joints flexed and the IP joints extended (Fig. 15-6K).
VARIATIONS IN TECHNIQUE
Even in a small area like “no man's land,” there can be considerable variation in the type of injury and the
specific surgical techniques required for repair.
Management of FDS lacerations: Recommendations for treatment of FDS lacerations in zone II have ranged
from repair to tendon excision, with multiple techniques recommended for repair. In more proximal injuries,
excision of a slip or all of the FDS should be considered if the combined repair of the FDP and FDS will not
easily pass under the A2 pulley. This is a special problem in zone IIc, just proximal to the split in the FDS tendon
and beneath A2, where routine FDS excision may offer a better final result (11).
Alternate suture techniques: The goal of any tendon suture is to be strong enough to allow early motion, be
flexible enough and have minimal bulk to allow tendon gliding, and be easy enough to do without damaging the
tendon. Numerous suture techniques have been proposed for flexor tendon repairs (Fig. 15-8), varying in
stiffness; ease and speed of placement; size, location, and number of knots; and suture material. In general,
repair strength is related to the thickness and tensile strength of the suture (22) and the number of passes
across the tendon repair site.
The suture knot may be left in the tendon repair site or incorporated into the tendon distant from the repair,
allowing greater surface area for intrinsic tendon healing, as demonstrated in the FDS repair in Figures 15-6D
and 15-8G. The epitendinous suture may be placed around the dorsal surface of the tendon prior to core suture
placement or may be placed in its entirety first, followed by placement of the core suture (23).
Pulley excision/venting: It is frequently necessary to “vent” either A2 or A4 by making an incision on the pulley's
lateral border, either to aid in tendon exposure to allow placement of a core suture (especially in A4) or to allow
the tendon repair to pass easily into the pulley system (more commonly A2) (24). While pulley preservation is
preferred, venting or complete release of A4 (14) and release of up to the distal 75% of A2 are acceptable to
avoid a tendon repair that will trigger or not pass under the pulley (25).
Anesthesia: While regional anesthesia is usually used in our practice, “wide awake local anesthesia” (26) or
local anesthesia with epinephrine, sedation, and no tourniquet can offer benefits in some patients. Active motion
can be tested intraoperatively, as can the tendency of the repair to gap with gentle motion. A repair that gaps or
“bunches” can be redone.
Management of partial lacerations: Unless noted intraoperatively, diagnosis and quantification of partial flexor
tendon injuries in zone II can be difficult. Pain on resisted flexion testing—possibly with a flexion lag—may be the
only physical finding. If there is a significant lag and concern about a significant partial laceration, ultrasound may
be a useful diagnostic tool (27).
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FIGURE 15-8 A limited list of 2-, 4-, and 6-strand repairs. Eight-strand repairs are possible using looped sutures.
All of these are combined with a simple epitendinous running “tidying” suture. A: Kessler (Ref. 17). B: Modified
Kessler, with knots inside repair. C: Bunnell. D: Strickland (Indiana). E: Modified Becker (MGH) (Ref. 18). F:
Four-strand cross-grasping (Adelaide) (Ref. 15). G: Four-strand suture with knot buried in tendon away from
repair (Peter Evans MD, PhD, personal communication). H: Six-strand cross-grasping (Ref. 19). I: Six-strand
looped suture (Ref. 20). An excellent review of suture techniques can be found in the article by Chauhan et al.
(21).
Partial lacerations affect tendon function by interfering with gliding of the tendon within the sheath and, to a
lesser degree, weakening the tendon. Lacerations on the volar surface of the tendon affect gliding to a greater
degree than lateral lacerations (28). Tendon flaps can trigger as they pass the pulleys, even with an intact
sheath, with distally oriented oblique lacerations more likely to trigger. Beveling or debridement of lacerations of
up to 75% of the tendon thickness is usually adequate, with one study suggesting that immobilization or core
suture repair of 60% partial lacerations actually weakened the final tendon strength (29) and another suggesting
inferior clinical results (30). Repair is reserved for larger lacerations, and possibly for FDP repairs following FDS
excision. A simple running peripheral repair is usually adequate, although a core suture can be added for higher-
grade lacerations.
Rehabilitation is limited by any complete lacerations that were repaired. For partial injuries alone, an accelerated
protected motion program can be initiated, with full active motion allowed from the time of initial presentation,
strengthening in 2 to 4 weeks, and unrestricted activity in 4 to 6 weeks, depending on the degree of injury.
Flexor tendon lacerations in children (31,32): While less common than adult injuries, small children present a
unique set of challenges. Exposure is through a zigzag Bruner-type incision, as midlateral incisions may cause
delayed flexion contractures. Small tendons make core sutures difficult, but two-strand repairs carry a higher
rupture risk. A Kessler suture augmented with a horizontal mattress or multiple figure-of-eight sutures can be
used, with a simple epitendinous suture. It is difficult to keep the locking sutures far enough from the repair, and
the suture knot is often large relative to the size of the tendon. Pulley venting is often required, and the FDS left
unrepaired. Rehabilitation protocols will depend on the patient's age and compliance. While active motion
programs are preferred, children may do better than adults with immobilization.
PEARLS AND PITFALLS

Recognize that the skin laceration may be well proximal to the tendon laceration, especially in injuries that
occur with a clinched fist.
Do not hesitate to make a small palmar incision, release the A1 pulley, and pass the tendons into the digit if
not easily retrieved. This is better than damaging the interior of the tendon sheath or epitenon with repetitive,
unsuccessful attempts at retrieval.
Maintain alignment and relationship of FDP and FDS. Pay attention to blood vessels on the dorsal side of FDP
and to the rotation of the slips of the FDS.
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Careful passage of tendons under pulleys. Avoid damaging tendon ends with multiple or rough attempts at
passage.
“Back-side-first” epitendinous repair is helpful to align tendons and aid in placement of the core suture.
Prevent “intussusception” of tendon as the core suture is placed, a problem seen more with thicker or braided
sutures.
Post-op motion will not be any better than intra-op motion. Make sure there is no “bunching” or gapping at the
tendon repair site. Vent or partially excise the pulley if needed. Sheath repair may help or hinder the repair's
passage under a pulley.
Use thin, tapered needles on the core suture so as not to tear the tendon or damage the epitendinous suture.
Rehabilitation after surgery should promote the biology of tendon healing. Both extrinsic tendon healing
(between the tendon and surrounding sheath) and intrinsic tendon healing (direct healing of the tendon ends to
each other) occur. Different rehabilitation protocols alter the relative amounts of each type of healing, with
immobilization leading to more extrinsic healing and early mobilization leading to less tendon adhesion and more
intrinsic healing (33).
Early motion programs provide a clear benefit when compared to prolonged immobilization protocols. There is a
more rapid improvement in repair tensile strength, increased tendon excursion, less adhesion formation, and less
repair site deformation (34). Early motion programs consist of active extension-passive flexion methods,
controlled passive motion approaches, early active motion programs, and a combination of the above. The most
effective mobilization strategy remains controversial. A program with gradual motion advancement requires the
coordinated effort of the surgeon, a qualified hand therapist, and a cooperative patient to work well.
Kleinert first proposed an extension block orthosis equipped with rubber bands, which allowed active digital
extension against a constant, passive flexion recoil force (35). Duran and Houser initially used a controlled
passive motion protocol at the MP and IP joints, noting that this method afforded 3 to 5 mm of excursion capable
of avoiding adhesions (36). Current “active motion” protocols allow active maintenance of passively achieved
digital flexion after the wrist has been moved from flexion into extension.
While early motion programs allow better and faster recovery of motion, they do not alter the time it takes for the
tendon repair to reach full strength. Rather than follow a rigid rehabilitation protocol, we modify the program
based on the patient's response to exercise, with the goal of a gradual return to full motion. Patients who are
stiffer will advance to more strenuous exercises earlier, while those who are unusually supple or have unusually
good early active motion will have more limited active exercises.
Therapy is usually initiated within the week following surgical repair. At the first visit, a custommade
thermoplastic or off-the-shelf dorsal extension block splint is applied with the wrist neutral, the MP joints flexed
70 to 90 degrees and the IP joints in extension (Fig. 15-9). A palmar bar across
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the MP joints will stabilize the hand and keep it from lifting out of the splint. The patient starts with passive motion
exercises, bringing the digits into a clenched-fist position with the splint in place. This can be done either
passively or with the aid of rubber bands attached to the nail plates, passed through a palmar pulley, and
attached to a hook at the wrist. This allows passive flexion, which the patient can actively extend against.
Attention must be paid to assure that the patient does not develop interphalangeal joint flexion contractures. A
piece of foam placed behind the proximal phalanges in the splint will assure that full PIP extension remains
possible.
FIGURE 15-9 An “off-the-shelf” dorsal block splint. The wrist is neutral, the MP joints are flexed, and the IP joints
are extended. These can also be custom made by the occupational therapist.
Gentle “place and hold” active exercises can begin in the first week for secure four-strand repairs in compliant
patients. In other cases, this is delayed until the patient is 3 to 4 weeks from surgery. Actively, the patient
maintains the passively achieved fist position as the wrist is brought into 20 to 30 degrees of extension for
several seconds. Following this sequence, the patient drops the wrist back into flexion, and the digits are allowed
to extend. This cycle is repeated several times per hour each day. High grip forces are discouraged.
After approximately 4 to 6 weeks, the splint is removed for gentle active and passive exercises but worn between
exercise sessions. The splint is removed after 6 weeks, at which time more vigorous passive extension exercises
and blocking exercises are started. Strengthening is introduced at 8 to 10 weeks postoperatively in a progressive
fashion.
Prolonged periods of postoperative immobilization with casting are typically avoided, except for unique
populations, including children and noncompliant patients. In these patients, a short arm cast (supinated long
arm in small children) is applied with the wrist in neutral position. When dry, the cast is extended out over the
fingers with the MPs flexed and the IPs extended. The palmar surface of the cast from the MP joints distally is
removed to prevent isometric contraction against the cast and to allow a gentle passive program. The cast is
continued for 4 to 5 weeks (3 to 4 weeks in small children), at which time active motion without resistance is
allowed.
COMPLICATIONS
Postoperative stiffness: This can result from tendon adhesion formation, interphalangeal joint contractures,
or a combination of both. Adherent tendons do not glide appropriately, leading to decreased active motion
with relatively little restriction of passive flexion. A small or moderate flexion contracture may be present.
Risk factors for tendon adhesion include immobilization, gapping at the repair site, associated injuries, and
trauma to the tendon from the original injury and the following surgical manipulation. Formal occupational
therapy, including active motion and strengthening (once it is felt the repair is adequately healed), is helpful.
Tenolysis can be considered 4 to 6 months after the initial repair if serial examinations fail to show
improvement in active range of motion, if passive range of motion is near full, and if the surrounding bone
and soft tissues are satisfactorily healed.
Interphalangeal joint contractures: These can occur in any patient but are a special concern in those
treated with rubber band traction or immobilization. If identified early, this complication usually resolves after
a period of passive stretching and/or static progressive splinting. When significant loss of joint motion
remains after 4 to 6 months of dedicated conservative therapy, the patient should be considered for
contracture release. This is best performed under a local anesthetic, so that the effectiveness of the release
can be assessed and tenolysis can be performed for the almost always coexistent tendon adherence.
Tendon rupture: Disruption of the repaired flexor tendons is a serious but uncommon complication,
occurring in 2% to 7% of patients, most commonly within the first couple of months following surgery
(37,38). Risk factors include the mechanism of injury, quality of repair, presence of infection, rehabilitation
protocol, age, and patient compliance. New traumatic insults, excessive movement during rehabilitation
exercises, overzealous lifting or gripping motions, and inadvertent actions during sleep can all lead to
rupture. Clinical exam typically demonstrates both a lack of strength and active motion. Examination can be
difficult, especially early in the postoperative period where digital stiffness may mask a rupture. If
suspicious, ultrasound or MRI may aid in diagnosis. Management includes prompt diagnosis, operative
exploration, and repair. Tendon passage under the pulleys is more difficult, and the FDS is generally not
repaired. Scarring and tendon retraction can complicate repair attempts. The patient and surgeon should be
prepared for a possible interpositional graft, arthrodesis, or initiation of a two-stage flexor tendon
reconstruction.
Infection: This is generally unusual following tendon repair but may result in cases with gross wound
contamination on initial presentation. Early irrigation and debridement, followed by resumption of a
protected passive motion program is recommended. Depending on surgical findings, early active motion
may be discouraged. Delayed treatment is often associated with tendon rupture.
Triggering: Bulky tendon repairs and unrecognized partial tendon lacerations can lead to triggering of the
digit. Intraoperative assessment of tendon gliding after repair is important to identify any
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resistance or catching as the repair enters or exits the pulley. Pulley venting, partial sheath excision, and
tendon “beveling” can help prevent this complication (39).
Other complications include iatrogenic neurovascular injuries, chronic regional pain syndromes, and scar
contractures.
RESULTS
While good to excellent results can be expected in 80% of patients with zone II flexor tendon lacerations
(34), many challenges remain in the management of these injuries. In general, results have improved as
more secure repair techniques have allowed earlier institution of active motion. Risk factors for a poor result
include other associated injuries, such as fracture or nerve lacerations, crush injuries, repair done more
than a couple of weeks after the original injury, smoking, and age.
Countless contributors have guided our understanding of tendon injuries and repair (34). Our approach to
tendon repairs has changed considerably and continuously since Verdan and Kleinert's initial proposal to
proceed with primary repair in zone II injuries. Future developments will revolve around a better
understanding and individualization of rehabilitation programs, better monitoring of tendon repairs during the
postoperative period (e.g., with ultrasound), novel tendon repairs (e.g., barbed, knotless sutures) (40) and
novel repair devices (41), and agents to decrease tendon adhesion (34,42,43,44,45). In the meantime,
attention to surgical detail; a smooth, strong tendon repair; and a thoughtful, early motion therapy program
will provide the best chance of a good or excellent recovery, preventing zone II from becoming McCash's
“deathbed of [the] profundus.”
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2. McCash CR: The immediate repair of flexor tendons. Br J Plast Surg 14: 53-58, 1961.
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11. Tang JB. Flexor tendon repair in zone 2C. J Hand Surg Br 19(1): 72-75, 1994.
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Surg Am 14(2 Pt 1): 262-267, 1989.
13. Starnes T, Saunders R, Means K: Clinical outcomes of flexor tendon zone II repair depending on
mechanism of injury. J Hand Surg Am 37(A): 2532-2540, 2012.
14. Franko OI, Lee NM, Finneran JJ, et al.: Quantification of partial or complete A4 pulley release with FDP
repair in cadaveric tendons. J Hand Surg Am 36(3): 439-445, 2011.
15. Sandow MJ, McMahon M: Active mobilisation following single cross grasp four-strand flexor tenorrhaphy
(adelaide repair). J Hand Surg Eur Vol 36(6): 467-475, 2011.
16. Le SV, Chiu S, Meineke RC, et al.: Number of suture throws and its impact on the biomechanical
properties of the fourstrand cruciate locked flexor tendon repair with FiberWire. J Hand Surg Eur Vol 37(9):
826-831, 2012.
17. Kessler I. The “grasping” technique for tendon repair. Hand 5(3): 253-255, 1973.
18. Greenwald DP, Hong HZ, May JW Jr: Mechanical analysis of tendon suture techniques. J Hand Surg Am
19(4): 641-647, 1994.
19. Sandow MJ, McMahon MM: Single-cross grasp six-strand repair for acute flexor tenorrhaphy. Atlas Hand
Clin 1(1): 41-64, 1996.
20. Lim BH, Tsai TM: The six-strand technique for flexor tendon repair. Atlas Hand Clin 1(1): 65-76, 1996.
21. Chauhan A, Palmer BA, Merrell GA: Flexor tendon repairs: techniques, eponyms, and evidence. J Hand
Surg Am 39(9): 1846-1853, 2014.
22. Taras JS, Raphael JS, Marczyk SC, et al.: Evaluation of suture caliber in flexor tendon repair. J Hand
Surg Am 26(6): 1100-1104, 2001.
23. Papandrea R, Seitz WH Jr, Shapiro P, et al.: Biomechanical and clinical evaluation of the epitenon-first
technique of flexor tendon repair. J Hand Surg Am 20(2): 261-266, 1995.
24. Kwai Ben I, Elliot D: “Venting” or partial lateral release of the A2 and A4 pulleys after repair of zone 2
flexor tendon injuries. J Hand Surg Br 23(5): 649-654, 1998.
25. Tanaka T, Amadio PC, Zhao C, et al.: The effect of partial A2 pulley excision on gliding resistance and
pulley strength in vitro. J Hand Surg Am 29(5): 877-883, 2004.
26. Lalonde DH: Reconstruction of the hand with wide awake surgery. Clin Plast Surg 38(4):761-769, 2011.
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27. Lee DH, Robbin ML, Galliott R, et al.: Ultrasound evaluation of flexor tendon lacerations. J Hand Surg
Am 25(2): 236-241, 2000.
28. Erhard L, Zobitz ME, Zhao C, et al.: Treatment of partial lacerations in flexor tendons by trimming. A
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29. Bishop AT, Cooney WP III, Wood MB: Treatment of partial flexor tendon lacerations: the effect of
tenorrhaphy and early protected mobilization. J Trauma 26(4): 301-312, 1986.
30. McGeorge DD, Stilwell JH: Partial flexor tendon injuries: to repair or not. J Hand Surg Br 17(2): 176-177,
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31. Al-Qattan MM: Flexor tendon injuries in the child. J Hand Surg Eur Vol 39(1): 46-53, 2014.
32. Nietosvaara Y, Lindfors NC, Palmu S, et al.: Flexor tendon injuries in pediatric patients. J Hand Surg Am
32(10): 1549-1557, 2007.
33. Gelberman RH, Woo S, Amiel D, et al.: Influences of flexor sheath continuity and early motion on tendon
healing in dogs. J Hand Surg 15(A): 66-77, 1990.
34. Strickland JW: Development of flexor tendon surgery: twenty-five years of progress. J Hand Surg Am
25(2): 214-235, 2000.
35. Kleinert HE, Kutz JE, Atasoy E, et al.: Primary repair of flexor tendons. Orthop Clin North Am 4(4): 865-
876, 1973.
36. Duran RJ, Houser RG: Controlled passive motion following flexor tendon repair in zones II and III. In:
Hooper G, ed. AAOS symposium on tendon surgery of the hand. St. Louis, CA: C.V. Mosby, 1975: 105-114.
37. Harris SB, Harris D, Foster AJ, et al.: The aetiology of acute rupture of flexor tendon repairs in zones 1
and 2 of the fingers during early mobilization. J Hand Surg Br 24(3): 275-280, 1999.
38. Dy CJ, Daluiski A, Do HT, et al.: The epidemiology of reoperation after flexor tendon repair. J Hand Surg
Am 37(5): 919-924, 2012.
39. Momeni A, Grauel E, Chang J: Complications after flexor tendon injuries. Hand Clin 26(2): 179-189,
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40. Peltz TS, Haddad R, Scougall PJ, et al.: Performance of a knotless four-strand flexor tendon repair with a
unidirectional barbed suture device: a dynamic ex vivo comparison. J Hand Surg Eur Vol 39(1): 30-39, 2014.
41. Su BW, Solomons M, Barrow A, et al.: Device for zone-II flexor tendon repair. A multicenter, randomized,
blinded, clinical trial. J Bone Joint Surg Am 87(5): 923-935, 2005.
42. Baymurat AC, Ozturk AM, Yetkin H, et al.: Bio-engineered synovial membrane to prevent tendon
adhesions in rabbit flexor tendon model. J Biomed Mater Res A 103(1): 84-90, 2015.
43. Zhao C, Sun YL, Kirk RL, et al.: Effects of a lubricin-containing compound on the results of flexor tendon
repair in a canine model in vivo. J Bone Joint Surg Am 92(6): 1453-1461, 2010.
44. Zhao C, Wei Z, Reisdorf RL, et al.: The effects of biological lubricating molecules on flexor tendon
reconstruction in a canine allograft model in vivo. Plast Reconstr Surg 133(5): 628e-637e, 2014.
45. Zhao C, Sun YL, Jay GD, et al.: Surface modification counteracts adverse effects associated with
immobilization after flexor tendon repair. J Orthop Res 30(12): 1940-1944, 2012.
Chapter 16
One- and Two-Stage Reconstructive Approaches for Intercalary
Flexor Tendon Deficiency
Michael W. Neumeister
Brian M. Derby
Bradon J. Wilhelmi
INTRODUCTION
Tendon lacerations in the hand are common. Primary tendon repair follows the principles of tendon repair that
have evolved to today's debates on repair techniques, core suture number, and early mobilization (1,2).
However, primary end-to-end repair is occasionally not possible and tendon grafting is needed. Alternatively, the
desired outcome of the primary repair is unacceptable, and secondary procedures are required to restore
function. The secondary procedures may include tenolysis, tendon transfer, tendon grafting (single- and two-
stage approaches), and pulley reconstruction. Tenolysis alone to restore function requires and intact tendon and
pulley system. Intercalary tendon grafting is needed when the substance of the tendon is absent. Lexer reported
on the first series of flexor tendon graft use in the hand in 1912 (3). In 1963, Basset and Carroll described
secondary reconstruction of tendons using silicone implants. Later in 1971, Hunter expanded upon the staged
technique of flexor tendon reconstruction (4).
Intercalary tendon grafting and pulley reconstruction are discussed in detail in the pages that follow.
INDICATIONS AND CONTRAINDICATIONS

Tenolysis procedures are occasionally required to release adherent tendons from the bone or surrounding soft
tissue. The fingers usually have good passive motion but poor active motion. Periarticular contractures may also
contribute to poor motion at the metacarpal (MP) or interphalangeal (IP)
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joints (proximal interphalangeal, PIP, and distal phalangeal, DIP). Complete release of all offending restrictive
soft tissue fibrosis will aid in the postoperative active and passive range of motion (4,5,6,7,8). The timing of
tenolysis after primary repair, or reconstructive grafting, has been controversial. Most authors recommend
waiting 3 months after the initial surgery and when therapy plateaus before embarking upon tenolysis (2,6,8).
Prior to this tenolysis may endanger nutritional supply and increase risk of rupture (8).
Intercalary tendon grafting can be divided up into two groups: single stage, which is generally considered acute
(primary), and two stage, which is delayed (secondary) (4). The indications for acute single-stage free tendon
graft are limited (4) (Table 16-1). Outside of these narrow parameters for acute single-stage graft repair, two-
stage tendon grafting is performed. Boyes provided a preoperative injury classification system meant to aid in
decision making for primary or secondary tendon grafting (8,9,10) (Table 16-2). Outside of Boyes' level 1, most
tendon grafting (Boyes' levels 2 to 5) will need a staged reconstruction. In general terms, most surgeons use the
criteria in Table 16-3 for their indications for staged tendon grafting.
Contraindications to tendon grafting are included in Table 16-4 (2,3,4). In an attempt to salvage useful finger
function in more significantly damaged fingers (Boyes' grades 2 to 5), two-stage reconstruction should be
pursued. Also, if the pulley systems require reconstruction, single-stage reconstruction should be abandoned,
and efforts turned to two-stage reconstruction (2). With all of this information in mind, a well-informed consent is
fundamental. Each patient needs to understand that an intraoperative evaluation of the tendons during tenolysis
procedures, primary tendon repair or grafting, or joint releases may require a staged reconstruction to provide
the optimum result.
TABLE 16-1 Indications for Acute Single-Stage Free Tendon Graft
1. Injuries resulting in segmental tendon loss
2. Delayed presentation greater than 3 weeks, resulting in tendon end fraying and retraction from
muscle belly contraction
3. Delayed presentation of some FDP avulsion injuries
TABLE 16-2 Boyes Injury Classification for Tendon Grafting
Grade 1—Minimum scar, supple joints, no trophic changes
Grade 2—Scar limiting gliding of graft
Grade 3—Joint involvement with loss of passive motion
Grade 4—Multiple digit involvement with tendon injury
Grade 5—Devastating injury with salvage procedures required
TABLE 16-3 Indications for Flexor Tendon Grafting
1. Late rupture of flexor repair
2. Rupture or gap at tenolysis
3. Late presentation after injury
TABLE 16-4 Contraindications to Tendon Grafting
1. Insensate digit
2. Poorly vascularized fingers
3. Patients who cannot appreciate the needs for strict adherence to postoperative hand therapy
regimens (i.e., children <3 years, mentally debilitated)
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SURGICAL TECHNIQUES
Tendon Grafting
For the sake of brevity, the tendon grafting techniques are described for flexors of the hand only. There are
many tendons that can be readily harvested with minimal donor site morbidity (Table 16-5). The ipsilateral
palmaris longus tendon and the plantaris tendon are the most commonly employed used for grafting (2,3,4). The
palmaris longus and plantaris tendons are not always present but luckily are found in 85% and 80% of subjects,
respectively (2,3,4,5,6). Intrasynovial toe flexor grafts, in theory, replace like with like, but they are not as
commonly used. Finally, Paneva-Holevich described an intrasynovial grafting technique that utilizes the flexor
digitorum superficialis or sublimis (FDS) for the flexor digitorum profundus (FDP) reconstruction (11).
TABLE 16-5 Tendon Graft Selection: Based on Length and Repair Number
Tendon Pure Tendon (cm) Within Muscle (cm) Total Length (cm) Width (mm)
EIP 10 (8-19) 3 13 3 (2-6)
EDM 11 (5-19) 5 16 3 (1-5)
PL 13 (8-19) 3 16 3 (2-6)
Plant. 31 (10-40) 4 35 2 (1-4)
Toe extensors 30 (22-239) 5 35 2.5 (2-4)
Wehbé MA.Tendon graft donor sites. J Hand Surg Am 17(6):1130-1132, 1992.
Tendon Harvest
The palmaris longus tendon provides ample length for a tendon graft to be passed from the distal phalanx
(Verdan zone 1) to the palm (Verdan zone 3).The presence of the palmaris longus tendon is performed
preoperatively by having the patient oppose the thumb and small finger with the wrist flexed against resistance
(Fig. 16-1). The palmaris longus tendon is harvested with a limited transverse incision at the distal wrist crease,
transected, passed through a tendon stripper, and then held securely as the stripper is passed proximally with a
slight twisting motion (Fig. 16-2). Advancing the stripper proximally will allow the tendon to be pulled distally as it
separates from its muscle belly.
Tendon grafts that are passed from the distal phalanx to the forearm (Verdan zone 5) require a longer length
making the plantaris tendon a good choice. The plantaris is harvested by a small incision anterior to the medial
border of the Achilles tendon (Fig. 16-3A). The technique of harvest is
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similar to that of the palmaris longus tendon using a longer tendon stripper and moving the stripper proximally up
the lower leg (Fig. 16-3B-E). Compartment syndrome after plantaris harvest has been reported secondary to
bleeding (4). The signs and symptoms of hematoma and compartment tightness should be evaluated prior to
discharging the patient home from the tendon grafting procedure.
FIGURE 16-1 Palmaris longus tendon is more prominent when the thumb is opposed to the little finger and the
wrist is flexed. (From Derby BM, Wilhelmi BJ, Zook EG, et al.: Flexor tendon reconstruction. Clin Plast Surg
38(4): 607-619, 2001.)
FIGURE 16-2 To harvest the palmaris longus tendon, a small incision is made at the distal wrist crease over the
palmaris longus tendon. The tendon is held while it is transected distally, and a tendon stripper is placed along
the tendon sheath into the proximal forearm to release the tendon from its muscle belly. (From Derby BM,
Wilhelmi BJ, Zook EG, et al.: Flexor tendon reconstruction. Clin Plast Surg 38(4): 607-619, 2001.)
FIGURE 16-3 A: The plantaris tendon is harvested from the medial ankle area just anterior to the Achilles
tendon. B, C: The Achilles tendon is identified and retracted posteriorly, and the plantaris tendon can be
visualized just anterior to it. D, E: The plantaris tendon is held out to length and is transected, and the tendon
stripper is placed up into the calf releasing it from its muscle belly. (From Derby BM, Wilhelmi BJ, Zook EG, et al.:
Flexor tendon reconstruction. Clin Plast Surg 38(4): 607-619, 2001.)
Single-Stage Grafting
The single stage, acute tendon graft requires a supple finger with intact pulleys. Intercalary tendon grafts are not
used in zone 2 because of the bulk of the two sites of repair. The intercalary graft, then, is used to bridge zone 2
most commonly from zone 1 to zone 3. However, intercalary grafts can be used acutely for segmental loss of
tendon in all other zones. In the digit, a Bruner zigzag incision or the midlateral approach is acceptable for entry
to the fibro-osseous canal. The midlateral approach should not be used if a zigzag approach has been used
previously (2). The tendon sheath and pulley system are preserved (2,3,4). If present, the distal profundus stump
freshened preserving the most distal 1 cm. The undersurface of the distal FDP tendon is elevated exposing
some of the distal phalanx, which is roughened with a rongeur in preparation for the insetting of the tendon graft.
The proximal FDP tendon proximal to zone 2 is trimmed back to healthy tendon (2,3). The scarred or damaged
FDS tendon is usually removed as well. The amount of scarring within the fibro-osseous canal will determine if
the surgeon can continue with a single-stage tendon graft. Excessive scarring would preclude the single-stage
procedure, making the surgeon convert to a two-stage reconstruction. With respect to the dealing with FDS
tendon, there is some controversy. If the FDS is intact upon exploration, the FDP can still be grafted through the
decussation if the scarring is limited. But the surgeon should be aware that by grafting through the slips of the
FDS, scarring may limit not only the FDP function but also that of the FDS rendering the finger stiff and
functionless. An FDS-only finger is still very functional. Pulvertaft warned “it should not be advised unless the
patient is determined to seek perfection and the surgeon is confident of his ability to offer a reasonable
expectation of success without the risk of doing harm” (2). The best candidates for FDP grafting through the FDS
are those with high occupational demands for dexterity, such as skilled technicians or musicians, generally ages
10 to 21 years (2,3,4).
The most common type of FDP reconstruction is performed in the situation where there is not a functional FDS
present, and therefore, a one-tendon finger is created. The tendon graft is passed through the intact pulley
system and secured to the distal phalanx. The tendon graft is secure under the remnant stump of the FDP
tendon juxtapositioned against the roughened bone. The tendon is secured to the distal phalanx by either
passing the suture through the phalanx or passing around the bone on Keith needles. A 3-0 monofilament or
suture wire is used. If the suture is passed through the bone, the suture should be routed distally to exit through
the sterile matrix of the nail plate and tied over a button. As an alternative, suture anchors have also been used
at the distal graft juncture to provide a very strong bone-graft interface (2).
If present, then the distal FDP stump is sutured to the tendon graft with 3-0 suture as well. This secures the
distal tendon graft to heal and withstand rehabilitation. The proximal aspect of the tendon graft is commonly
repaired with a modified Pulvertaft end weave and sutured with 3-0 suture (4). In the palm (Verdan zone 3), the
repair is made just distal to the lumbrical origin. Tension on the graft is set to bring the finger into composite
flexion slightly greater than the normal cascade. A similar repair and tension is accomplished for proximal tendon
grafts into the forearm (Verdan zone 5).
Two-Stage Grafting
The basis of a two-stage reconstruction is that the fibro-osseous canal is hostile to the pristine gliding
environment needed by flexor tendons to function normally. The two-stage technique employs the body's natural
reaction to foreign bodies where a scar capsule or pseudosheath forms around the implant (Fig. 16-4A-D). The
pseudosheath is relatively thick and strong but more importantly has an extremely smooth inner surface, which
now provides a friendly gliding environment for the tendon graft (12). Therefore, the two-stage grafting involves
resection of scar and remnant tendon, reconstruction of the pulley/sheath system, and insertion of a silicone rod
to generate the pseudosheath. The patient and therapists work hard to keep the digit supple without contracture
while the pseudosheath forms. An adequate pseudosheath usually takes about 3 months to mature. The second-
stage tendon grafting procedure can then ensue. The Hunter implants used for staged reconstruction have a
polyester core and silicone elastomer shell, ranging in width from 2 to 6 mm (13).
During the first stage of the tendon grafting, the bed for the implant in the finger should be cleared of as much of
the scar tissue as possible. Contractures are corrected perhaps involving the release of the volar plate, collateral
ligaments, or the accessory collateral ligaments. The silicone implant (usually 4 to 6 mm in size) is placed in the
bed volar to the boney skeleton. The implant is secured by a similar method as described above for the single-
stage grafting technique. The proximal end of the
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implant is not secured, however, being free to have unimpeded motion in the proximal palm or forearm. Although
the implants are considered inert, they should be removed. With that in mind, there have been case reports of
silicone rod implants removed 18 and 25 years after implantation (13).
FIGURE 16-4 A: Stage tendon reconstruction is performed when there is a lack of fibro-osseous canal and
usually no pulleys. All scar tissue is removed to get the bed ready for placing the Silastic rod. B: Redundant
tendons are excised. C, D: The Silastic rod is fixed to the distal phalanx and placed under pulleys if they are
present, or pulleys are reconstructed at the time. The proximal end of the Silastic rod is not secured and is left
free in the palm or in the distal forearm. (From Derby BM, Wilhelmi BJ, Zook EG, et al.: Flexor tendon
reconstruction. Clin Plast Surg 38(4): 607-619, 2001.)
After at least 3 months of therapy and with the finger supple and absent of contractures, the second stage of the
reconstruction can begin. An x-ray is usually performed ahead of the surgery to make sure that the silicone
implant has remained as was placed in the first stage. It is not necessary to open the finger as was done in the
first stage to retrieve the implant and insert the graft. Instead, small chevron incisions are made at the distal end
of the volar finger, while slightly longer incisions are needed in the palm or forearm depending on where the
proximal tendon is to be repaired. The implant is identified, but care is taken not to disrupt the pseudosheath.
With the implant still in place, the tendon graft is sutured to the proximal end of the implant (Fig. 16-5A-C). The
implant is then pulled distally out through the distal incision. The tendon graft is released from the implant and
secured to the distal phalanx and native remaining FDP stump as described above for the singlestage
reconstruction.
The proximal motor is repaired to the tendon graft as described above in the single stage. Occasionally, the
adjacent FDP tendon can be used to motor the newly grafted finger, but the native FDP proximal tendon is most
commonly used if present and adequate.
Paneva-Holevich described a two-stage alternative to the use of extrasynovial grafts (i.e., palmaris longus
tendon, plantaris tendon) (13,14,15,16). The technique takes advantage of the residual proximal FDS tendon as
the graft in a spare parts-like scenario. In the first stage, the two proximal ends of the resected FDP and FDS
tendons are sutured together in a Pulvertaft manner. All other aspects of the staged procedure described above
are similar procuring the bed, removing scar tissue in the
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finger, releasing contractures, placing the silicone implant, and, finally, pulley reconstruction. At the second
stage, the previously sutured proximal FDS-FDP loop in the palm is identified first. An incision in the forearm
more proximal gains access to the FDS of the involved finger(s) that the FDP reconstruction is being performed
on. The FDS is transected at this level in the forearm, making sure that ample length is taken to reach from the
palm to the distal phalanx of the finger. The FDS is pulled out through the palm wound, which now acts as an
intrasynovial pedicled tendon graft. The free end of the FDS is sutured to the implant and pulled through the
pseudosheath and out a small distal incision. Appropriate tension is set and the distal tendon graft is fixed to the
distal phalanx as described above (9,13). The proximal loop junction heals by the time the second stage is
performed, leaving only a single tenorrhaphy during the second stage. Some authors prefer the Paneva-Holevich
procedure for staged tendon reconstruction in children (14,15).
FIGURE 16-5 A-C: At the second stage of the tendon reconstruction, the tendon graft is sutured to the proximal
end of the Silastic rod, and through limited incisions, the rod is pulled through the distal incision bringing the
tendon graft through the pseudosheath developed by the Silastic rod. The tendon is fixed distally and then the
tension set proximally and sutured with a Pulvertaft technique. (From Derby BM, Wilhelmi BJ, Zook EG, et al.:
Flexor tendon reconstruction. Clin Plast Surg 38(4): 607-619, 2001.)
Pulley Reconstruction
Options for pulley reconstruction include Okutsu's “three-loop” technique, Kleinert/Weilby's “shoelace
interweave” technique, Lister's “extensor retinaculum” technique, and Widstrom's “loop and a half” technique (5).
The pulley system should be reconstructed as much as possible with the minimum being A2 and A4 (4,5).
Reconstruction of A3 offers even greater efficiency (5). A1 and A5 can be considered expendable and an
unnecessary focus of reconstructive efforts. Extensor retinaculum, slips of FDS, or tendon grafts are typically
used for reconstruction (Fig. 16-6A-C).
Okutsu used a triple loop of tendon graft under the extensor mechanism for the A2 pulley and over the extensor
for the A4 pulley reconstruction. The graft is sutured to itself side to side and end to side and forms three strands
of tendon for a neopulley. The tendon should be drawn tight enough to permit tendon glide but not allow
bowstringing (5,17). Successful reconstruction can also be achieved by placing the graft under the extensor
tendons for A4 (3,4,17,18).
The Kleinert/Weilby technique utilizes a tendon weave through the remaining fibrous rim of the pulley undergoing
reconstruction. The extensor retinaculum from the wrist provides a good gliding surface for the underlying
tendon, but it has the lowest load to failure and the lowest mechanical efficiency as a result of difficulties with
setting, and maintaining tension on the reconstructed pulley (5).
Widstrom's technique uses a tendon graft that is passed around the phalanx and then weaved into itself like a
Pulvertaft, which is somewhat bulky (17).
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FIGURE 16-6 A-C: Different techniques can be utilized to reconstruct the pulley system either at the first stage
of a staged reconstruction or acutely if the wound bed is not too scarred. (From Derby BM, Wilhelmi BJ, Zook
EG, et al.: Flexor tendon reconstruction. Clin Plast Surg 38(4): 607-619, 2001.)
POSTOPERATIVE CARE AND REHABILITATION

Single-Stage Grafting
Typically, passive flexion is initiated immediately at the first postoperative visit and proceeds for the next 12
weeks. The hand surgeon must make the therapists aware if pulleys were reconstructed. The pulleys will need
to be protected while they mature. An external protective pulley ring wrapped around the finger is worn for 4 to 6
weeks.
Two-Stage Grafting
The postoperative rehabilitation protocols should follow those of primary tendon repair, which depend on the
type of repair and commitment of the patient. The dorsal plaster splint is applied in
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the operating theater. The splint extends past the fingertips, maintaining the wrist at 35 degrees of flexion, the
MCP joints at 60 to 70 degrees, and IP joints in neutral. Stage two therapy follows the course described above
for single-stage grafting. Active motion protocols also exist with the most common being a “place and hold”
technique. There is limited evidence, however, to dictate the most appropriate protocol to use in the
postoperative period. The same is true in systematic reviews and randomized prospective studies for primary
tendon repairs (19,20,21). Active flexion is initiated at 4 weeks. Passive extension is performed after 6 weeks.
Joint contracture can be countered with dynamic splinting at 6 to 8 weeks (12). Strengthening and blocking
exercises ensue after until full range of motion is achieved or the therapy plateaus from making progress. The
pullout sutures holding the distal tendon to the distal phalanx are removed at postoperative weeks 5 to 6.
OUTCOMES
Two-Stage Grafting
Boyes' criteria of distance from fingertip to distal palmar crease (DPC) after passive flexion (11). Boyes'
classification of surgical outcomes indicates that results are
Excellent if fingertip approximates the DPC
Good if fingertip is <2.54 cm from the DPC (or <2.54 cm + flexion contracture of 20 to 40 degrees)
Fair if fingertip is <3.31 cm from the DPC (or <3.31 cm + flexion contracture of 20 to 40 degrees)
Poor if fingertip is >3.31 cm from the DPC or with severe contracture
The outcome classification system of LaSalle and Strickland utilizes comparable parameters to that of
Boyes. Total passive motion (TPM) after stage one is compared to total active motion (TAM) after stage two
and expressed as a percent (15). This system designates outcomes as
Excellent if TAM = 75% to 100% of TPM
Good if TAM = 50% to 74% of TPM
Fair if TAM = 25% to 49% of TPM
Poor if TAM <24% of TPM
The results following flexor tendon grafting depend on numerous factors, including the patient's age,
preoperative evidence of scarring, joint involvement, and which digit is involved. The best motion following a
flexor tendon graft is achieved in the little finger and the least motion in the index finger. If conventional
tendon grafting is performed in fingers with minimal scar, full passive motion, and no trophic changes, 50%
to 65% should be able to flex within 1.25 cm of the DPC. In digits with scarring, joint contractures, or
multiple associated problems, fewer than half of the patients will have a similar degree of flexion. Patients
should be expected to improve their motion for 4 to 5 months after surgery and by 22 weeks will have
achieved 90% of their eventual motion. A tenolysis to improve motion should not be considered until 6
months after a conventional flexor tendon graft.
COMPLICATIONS AND MANAGEMENT

Tendon Grafting
Complications following tendon grafting are listed in Table 16-6. Tendon repair rupture occurs 3% to 9% of the
time in most reported series, with maximal risk occurring 10 to 12 days postoperatively (7). The surgeon may
need to perform a two-stage procedure if the rupture is not identified
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early when a re-repair should be considered. Alternatively, a DIP tenodesis or arthrodesis may be considered if
the FDS still functions to flex the PIP joint.
TABLE 16-6 Complications of Tendon Grafting
Rupture
Adhesions
Joint contracture
Infection
Silastic rod exposure
Synovitis
Tendon imbalance
Lumbrical plus
Quadrigia
Providing improper tendon length for the tendon grafts can be problematic. Tendon tensioning complications
include lumbrical plus and quadrigia deformities. Excessively long tendon graft can result in a lumbrical plus
deformity. The lumbrical plus deformity is a paradoxical extension of the digit while attempting to flex the finger.
The FDP needs to draw more proximally than it would if the graft were of appropriate length. But before the FDP
can flex the IP joints, the lumbrical is stretched so much that it acts to draw the IP joints into extension. The distal
FDP remains less powerful than the lumbrical and extension results.
The quadrigia effect ensues after an overly advanced/tensioned flexor tendon repair. The quadrigia effect is
when the maximal TAM of a reconstructed FDP tendon is reached prior to complete TAM of the FDP of adjacent
fingers. The other digits cannot accomplish full flexion because the FDP tendons to the long, ring, and small
fingers have a common muscle belly with finely tuned tendons attached to it. The index finger FDP often
originates from an independent belly and is not typically subjected to this problem. The latter three digits can
tolerate up to 1-cm advancement before the risk of quadrigia becomes an issue (4,18).
Another potential complication of staged reconstruction of the flexor tendons includes silicone synovitis occurring
in approximately 8% of two-stage procedures (5). Implant infection (4% incidence) necessitates removal,
debridement, and antibiotic treatment, until the finger becomes supple again. A staged reconstruction can ensue
at a later date.
CONCLUSION
Intercalary tendon grafts are not common because of the improvements made in primary tendon repair. At
times, however, the trauma results in segmental tendon loss that obviates the need for an intercalary graft.
Staged reconstruction requires time and dedication from the patient as therapy will be extensive.
Satisfactory results can be achieved following the principles of the tendon grafting techniques.
REFERENCES
1. Manske P: History of flexor tendon repair. Hand Clin 21: 123-127, 2005.
2. Neumeister MW, Amalfi A, Neumeister E: Evidence-based medicine: flexor tendon repair. Plast Reconstr
Surg 133(5): 1222-1233, 2014.
3. Strickland J: Delayed treatment of flexor tendon injuries including grafting. Hand Clin 21: 219-243, 2005.
4. Derby BM, Wilhelmi BJ, Zook EG, et al.: Flexor tendon reconstruction. Clin Plast Surg 38(4): 607-619,
2011.
5. Freilich A, Chhabra B: Secondary flexor tendon reconstruction, a review. J Hand Surg 32A(9): 436-442,
2007.
6. Boyer M, Taras J, Kaufmann R: Flexor tendon reconstruction. In: Green D, Hotchkiss R, Pederson WC, et
al., eds. Green's operative hand surgery. 5th ed., Vol. 1. Philadelphia, PA: Elsevier, 2005: 241-276.
7. Mehta V, Phillips C: Flexor tendon pulley reconstruction. Hand Clin 21: 245-251, 2005.
8. Azari K, Meals R. Flexor tenolysis. Hand Clin 21: 211-217, 2005.
9. Lehfeldt M, Ray E, Sherman R: MOC-PS CME article: treatment of flexor tendon laceration. Plast
Reconstr Surg 121(4): 1-12, 2008.
10. Boyes J, Stark H: Flexor tendon grafts in the fingers and thumb. J Bone Joint Surg 53A: 1332-1339,
1971.
11. Paneva-Holevich, E. Two-stage tenoplasty in injury of the flexor tendons of the hand. J Bone Joint Surg
51-A(1): 21-32, 1969.
12. Basheer M: Removal of a silicon rod 25 years after insertion for flexor tendon reconstruction. J Hand
Surg 32E(5): 591-592, 2007.
13. Hunter J, Salisbury R: Use of gliding artificial implants to produce tendon sheaths. Plast Reconstr Surg
45(6): 564-572, 1970.
14. Viegas S: A new modification of two-stage flexor tendon reconstruction. Tech Hand Up Extrem Surg
10(3): 177-180, 2006.
15. Beris A, Darlis N, Korompilia A, et al.: Two-stage flexor tendon reconstruction in zone II using a silicone
rod and a pedicled intrasynovial graft. J Hand Surg 28A(4): 652-660, 2003.
16. Darlis N, Beris A, Korompilias A, et al.: Two-stage flexor tendon reconstruction in zone 2 of the hand in
children. J Pediatr Orthop 25(3): 382-386, 2005.
17. Widstrom C, Johnson G, Doyle J, et al.: A mechanical study of 6 digital pulley reconstruction techniques:
part 1. Mechanical effectiveness. J Hand Surg 14A: 821-825, 1989.
18. Valenti P, Gilbert A: Two-stage flexor tendon grafting in children. Hand Clin 16(4): 573-578, 2000.
19. Thien TB, Becker JH, Theis JC: Rehabilitation after surgery for flexor tendon injuries in the hand.
Cochrane Database Syst Rev 18(4): CD003979, 2004.
20. Trumble TE, Vedder NB, Seiler JG III, et al.: Zone II flexor tendon repair: a randomized prospective trial of
active place-and-hold-therapy compared with passive motion therapy. J Bone Joint Surg 92(6): 1381-1389,
2010.
21. Chesney A, Chauhan A, Kattan A, et al.: Systematic review of flexor tendon rehabilitation protocols in
zone II of the hand. Plast Reconstr Surg 127(4): 583-1592, 2011.
Chapter 17
Selected Tendon Transfers for Median, Ulnar, and Radial Nerve
Deficits
Allan E. Peljovich
Benjamin J. Rogozinski
Michael W. Keith
INTRODUCTION
Peripheral nerve injuries of the upper extremities will leave individuals with real impairments. These impairments
tend to follow predictable patterns determined by the particular nerve(s) affected, the specific anatomic location
of the damage, and the extent of concomitant injuries to bone and soft-tissue structures. Fortunately, these
impairments can be mitigated or overcome by sophisticated orthotics/physiotherapy, individual compensation,
and operations designed to address some of the specific impairments. In the acute and subacute setting, elegant
techniques to repair and reconstruct damaged nerves are favored. Tendon transfers are typically performed
when nerve recovery is deemed impossible by the proximal location of an injury or a particularly large zone of
damage, when nerve reconstructions and/or transfers are contraindicated or have failed to result insufficient
reinnervation of paralyzed muscles, or even early following injury to minimize bracing (wrist extension transfer
and radial nerve palsy). This chapter discusses general concepts in thinking about and executing tendon
transfers and then illustrates these concepts and surgical techniques as they apply to median, ulnar, and radial
nerve deficits.
GENERAL INDICATIONS
Tendon transfer surgery is founded on the anatomical duplicity present in our upper extremities, that is, multiple
muscles mobilizing one joint. On the other hand, these techniques are limited by the inability to fully reconcile all
losses from paralysis. Donor muscles are not the biomechanical equivalent of the recipient muscles they are
“replacing” and come at some cost in terms of losing the original function of the donor. General indications are
outlined below:
Timing The individual's functional disabilities should be considered permanent. Operative techniques that
could restore peripheral nerve integrity should be considered to have precedence over tendon transfers,
unless there are extenuating circumstances that necessitate earlier functional improvement and the individual
is willing to make this choice. The anatomical environment should also be stable. Wounds should be fully
healed, any fractures should be united, and tissues should generally be in a state of equilibrium.
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Splinting/adaptations insufficient A variety of orthotics exist to help compensate for some of the function lost
by nerve palsies. Anticlawing splints for ulnar nerve palsy, soft opponens splints for median nerve palsies, and
metacarpophalangeal (MCP) extension splints for posterior interosseous nerve (PIN) palsy should be
entertained and trialed in individuals. Some individuals will decide that these modifications are sufficient, and
they seek no further treatment. Many will conclude that the braces are cumbersome, are tiresome, and/or fail
to produce a desired improvement, and surgery becomes an appropriate option for them.
Availability of appropriate donor muscles
Surgery should not sacrifice important present function in one joint to improve lost function in another.
The donor muscle should be biomechanically similar, and nearby, to the recipient muscle. For example, the
pronator teres (PT) might serve as a poor replacement for the flexor digitorum profundus (FDP if the
surgeon's goal is full finger flexion given its relative lack of excursion. Beware of using a donor muscle that
is weaker than the recipient if strength of restoration is important (Fig. 17-1).
The donor muscle should be relatively “intact,” that is, strong, free of injury, free of spasticity, and under the
individual's volitional control.
Availability of appropriate recipients
The surgeon should think in terms of lost functions, not muscles. For example, median nerve injury results
in loss of thumb opposition, not loss of the 3 thenar intrinsic muscles that contribute to opposition. The
limited nature of muscle redundancy requires the surgeon to perform an operation that restores the lost
function as precisely as possible given he/she will not be able to replace the loss of every paralyzed
muscle.
The recipient joints need to be supple. Tendon transfers do not treat stiffness.
Healthy tissue “bridge” Tendon transfers involve reorienting a muscle/tendon to a nearby, but new, insertion.
The tissue bridge between the donor and recipient should allow for excursion. In the setting of significant
trauma, tissue bridges made of skin graft devoid of subcutaneous fat and filled with previously placed internal
hardware, even when fully healed, may create an environment that promotes adhesions along the route of the
tendon transfer, limiting excursion.
Availability of resources Successful tendon transfer operations require frequent physiotherapy and frequent
office visits over the course of a few months. Individuals unable to manage both are unlikely to succeed.
Appropriate motivation “Learning” and incorporating tendon transfers into daily life requires individuals who
are committed and ready for this process. Good surgeon-individual communication is required to ensure that
an individual's needs are understood, the surgical expectations are appropriate (not excessive), and the goals
are realistically achievable.
FIGURE 17-1 The graph illustrates the relationship between potential excursion and potential force for the
forearm and hand muscles. This allows the surgeon to visualize muscles with similar properties and select donor
muscles that can match the recipient muscle properties. (From Berger RA, Weiss A-PC: Hand surgery.
Philadelphia, PA: Lippincott Williams & Wilkins, 2003.)
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CONTRAINDICATIONS
The reasons not to proceed with tendon transfer restoration in the setting of nerve palsies are similar regardless
of the actual palsy.
Individuals who do not perceive disability and feel “adapted” to their circumstance.
Insufficient time has passed from nerve insult to conclude the individual's physical state as a permanent one or
one that cannot be altered by other means.
An individual's physical examination, that is, degree of paralysis, recipient joint contractures, loss of tissue, or
state of tissue health, eliminates the realistic possibility of a successful tendon transfer procedure.
Individuals who lack the resources necessary to effect postoperative therapy.
Individuals who are not committed to the recovery process and therapy, in particular.
Individuals with greater than realistic expectations are a relative contraindication.
Developing a surgical plan follows a fairly routine algorithm. Adjustments and creativity are occasionally needed
in order to apply “standard” sets of tendon transfers to a particular individual's situation, that is, soft-tissue
damage compromises standard donor muscles or recipient tendons. The importance of good two-way
communication between the surgeon and the individual allows the creation of a sound strategy that will help
solve the individual's particular needs.
Identify the lost critical hand functions. What, exactly, needs restoration? The focus is on function as it relates
to how hands manipulate their environment and not the various muscles themselves. Low median nerve
damage compromises large object manipulation via loss of opposition. Ulnar nerve damage leads to multiple
impairments including compromised lateral pinch, inefficient finger flexion and clawing, and small finger
abduction, but not every functional loss requires reconstruction when there are limited options. Good surgeon-
individual communication is important here so as not to reconstruct elements of paralysis that do not require
treatment.
Distill each lost function into as few recipient muscles as possible. Restoration of finger flexion requires only
restoration of the FDP.
Identify available and biomechanically similar donor muscles to replace the lost recipient “function.” The
surgeon should review various alternative donor muscles (1) (Fig. 17-1).
The individual must be able to voluntarily contract the potential donor muscle.
The potential donor should have sufficient strength (BMRC ≥4).
Force of contraction should be sufficient for the lost function.
Muscle excursion (shortening) should produce sufficient functional motion.
Loss of the donor muscle's native function should not create real disability.
In-phase donor muscles are ideal and preferred, but not always necessary. Individuals who can learn to
volitionally contract the donor muscle will be able to learn the transfer, but it is substantially easier to
incorporate into their function when the donor muscle is already in phase to the lost function, that is, wrist
flexion and finger extension.
Ensure joint suppleness of the recipient “functions.” Early splinting and physiotherapy can maintain joints
following injuries, and surgery is sometimes required to release contractures prior to tendon transfer surgery.
Consider lost sensation from the nerve injury and how this could influence the decision to operate and the
result of surgery. All individuals are different and their “need” for good sensate skin in the operative plan. This
is a particular issue with median nerve palsies.
TECHNIQUE
Plan surgical approaches. Access to the donor tendon insertion and the access to mobilize the donor can be
through separate small approaches or a larger approach. Access to the recipient tendons may require a
separate exposure. Coaptation to restore extrinsic forearm flexors and extensor function should be placed
proximal to the carpal tunnel and extensor retinaculum whenever possible to avoid adhesions.
Mobilize the donor muscle. The force of donor muscle contraction can be diminished with the tendon sets off
at an angle to the body of the muscle and the orientation of its sarcomeres. While some transfers require
vector changes, most will do best when the muscle contraction is parallel to the tendon to maximize force. This
may require several small exposures or one larger exposure. The brachioradialis (BR) and the flexor carpi
ulnaris (FCU) are two examples of muscles with broad attachments that require mobilization (2,3).
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Avoid creating new areas of compression or friction. As the donor tendon is mobilized to a new area, the
surgeon will think about its orientation with respect to other muscles, sensory nerves, and blood vessels.
Recipient considerations. Bear in mind that the excursion that results at the coaptation site could create
sources of impingement or friction. This is particularly the case in transfers to restore the extrinsic extensor
and flexor tendons where they run under the extensor and flexor retinaculum, respectively.
Setting tension
Tendon transfer tension should be ideally set at the resting length of the donor muscle to maximize its
potential force of contraction (4). Setting transfers tightly simply put the muscle into the passive tension
portion of its Blix curve and create an inefficient donor muscle (5,6) (Fig. 17-2). The difficult part is
determining resting length, due to the lack of specialized equipment not currently commercially available
(7,8,9,10,11). The authors currently estimate the resting length by allowing the donor muscle to rest at its
natural tension prior to securing the coaptation. Hemostats placed on the donor tendon distal to the weave
allow the surgeon an opportunity to test the tension using proximal joint passive tenodesis prior to formally
securing the coaptation with sutures.
The position of the joint that mobilized via tendon transfer merits consideration as well. The resting length of
the donor muscle should be set about the midrange of functional motion of the “recipient” joint (12).
Tensioning at one end of motion will result in a transfer too loose at the opposite endpoint of range (Fig. 17-
2).
Tendon coaptation. The Pulvertaft weave continues to be a mainstay of transferring a donor tendon into a
recipient with strength and security, but is bulky (13,14). A variety of other techniques with biomechanical
robustness have also been reported including the “spiral linking technique,” the “double loop technique,” and
newer side-to-side repairs (30 to 34 JHS) (15,16,17,18,19) (Fig. 17-3).
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Vector considerations. The traditional teaching is a straight line of pull from donor muscle to recipient
insertion/transfer in order to minimize loss of contraction force from changes in angles. This line of pull, or
vector, can be altered to create particularly desirable effects (20). In the case of opponensplasties, the
surgeon can set the recipient thumb carpometacarpal motion from a spectrum of palmar abduction to
circumduction to adduction depending upon whether the transfer “pulls” from the radial side of the wrist to the
ulnar side and even distally from the hook of hamate (21,22). The surgeon can control how the transfer will
work and adjust the procedure to the patient's particular needs.
FIGURE 17-2 Blix curve is illustrated. Setting the tension during transfer is ideally performed at the donor
muscle's resting length, or the fiber length associated with the maximal potential active contraction force. Note
that at tensions set at longer fiber lengths, that is, tight transfers, the maximal potential active contraction force
actually decreases even though the overall “force” is greater due to the contribution from the passive stretch of
the muscle. (From Berger RA, Weiss A-PC: Hand surgery. Philadelphia, PA: Lippincott Williams & Wilkins, 2003.)
FIGURE 17-3 This operative photograph demonstrated the Pulvertaft tendon weave technique of tendon
coaptation. The donor tendon, the BR tendon in this photograph, is weaved into the recipient tendon, the FPL.
The donor tendon is weaved through the recipient tendon through a longitudinal slot in the center of the recipient
tendon created by either a specialized instrument or simple surgical knives and forceps. Multiple orthogonal
passes of the donor tendon into the recipient tendon create a nonlocking coaptation that allows tension to be set
once the weave is completed and then locked by multiple nonabsorbable sutures. The orthogonal passes instill
biomechanical strength and a large surface area for the tendons to heal into each other.
Postoperative protocols call for a period of immobilization to protect the coaptation for about 3 weeks, followed
by mobilization with splints and then transitioning to splint-free motion after about 6 to 8 weeks from surgery.
Once mobilization starts, individuals are taught important techniques using biofeedback to learn how to fire their
donor muscles to produce the desired recipient functions, and this is why in-phase donor muscles are easier to
rehabilitate. It is important for individuals to be motivated to continue working their transfers long after formal
therapy is concluded to help promote the neural learning required to make these transfers second nature.
MEDIAN NERVE PALSY

Indications
Median nerve paralysis tends to fall into two categories depending upon the anatomic location of the insult.
Low median nerve damage refers to injury distal to the extrinsic flexor motor points and affects the thenar
intrinsics and sensory innervation to the thumb/index/long/partial ring. The primary functional motor deficit is
the lack of thumb opposition (ulnar intrinsics prevent clawing of the index and long), and the primary
sensory deficit includes numbness to the thumb, index, long, and radial-sided ring fingers (Fig. 17-4).
Individuals seeking restoration should demonstrate difficulties with large object acquisition and lateral pinch.
Some can accommodate depending upon hand dominance, age, vocation, avocations, etc. High median
nerve damage occurs more proximally in the forearm and additionally affects some combination of the flexor
carpi radialis and palmaris longus (PL), the extrinsic finger flexors (except FDP to small and ring), the
forearm pronators, and the flexor pollicis longus (FPL). Sensory loss to the base of the thenar eminence
typically exists in high median nerve damage and can even occur in low damage provided the insult is just
distal to the last flexor digitorum superficialis (FDS) motor branch. This more disabling presentation creates
global problems with pinch and grasp, and individuals will nearly always seek options for improvement. The
surgeon should never overlook the problems associated with sensory deficits to the radial sided digits, and
should temper and/or incorporate how this affects the individual when rendering advice and formulating a
surgical plan.
FIGURE 17-4 This clinical photograph demonstrates the classic appearance of a hand with a low median
nerve palsy. The thenar eminence is markedly atrophied. The patient presented with difficulties
manipulating large objects using one hand and numbness in his radial fingers negatively affecting his
dexterity.
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Tendon transfer for low median nerve palsy is geared toward restoring thumb opposition, hence large object
acquisition. This motion is one of circumduction, a combination of palmar abduction and pronation (Fig. 17-5).
Opposition is typically a positional function placing the thumb in a position to pinch and/or manipulate a larger
object. Strength of pinch and manipulation are achieved via the ulnar innervated thenar intrinsics (adductor
pollicis [AdP], flexor pollicis brevis [FPB]) and the FPL. Even in cases of high median palsy, the ulnar-innervated
AdP and FPB can create sufficient force for pinch. Donor muscles therefore need to be strong enough to mimic
the abductor pollicis brevis (APB) and shorten enough to create thumb circumduction. A variety of donor muscles
have been utilized to restore opposition: FDS of the long or ring finger (not available in high median nerve palsy),
extensor indicis proprius (EIP), extensor pollicis longus (EPL), extensor carpi ulnaris (ECU), extensor carpi
radialis longus (ECRL), extensor digiti quinti (EDQ), PL, and abductor digiti minimi (ADM)
(21,23,24,25,26,27,28,29,30,31,32,33,34,35,36). A still utilized classic technique to restore opposition was
described by Bunnell using a donor muscle/tendon moving through a constructed pulley at the level of the
pisiform, across the palm, and to the dorsal ulnar aspect of the thumb metacarpal (37).
The additional impairments associated with high median nerve palsy depend upon the location of the damage
with respect to the nerve's various branches in the forearm. These impairments may include loss of index and
long finger flexion (loss of both FDP and FDS), weakening of ring and small flexion (loss of FDS), loss of forceful
forearm pronation (PT and pronator quadratus [PQ]), and loss of thumb interphalangeal flexion (loss of the FPL).
The loss of radial-sided flexion contributes to significant disability via the loss of various pinch patterns and the
weakening of palmar grasp. Preoperative assessment will determine the extent to which any loss of forceful
pronation is a real issue with the individual and will depend upon their vocations and avocations given that
shoulder abduction and BR contraction will produce a forearm pronation moment. The added loss of all the FDS
muscles necessitates alternative donor muscle for opposition among the potential donors previously listed. The
EIP and ADM are common donor options in this setting. The FPL is often restored using the BR as the donor
muscle, and index and long flexion are reanimated using side-to-side transfers of the ulnar-innervated FDP
(28,38). In circumstances where independent index or index/long flexion is needed, the ECRL can be used as a
donor motor for the radial-sided FDP muscles (28,39,40).
Two anatomical variations in forearm nerve anatomy between the median and ulnar nerves can affect the
individual's pattern of presentation. Both uncommon, the Martin-Gruber and Riche-Cannieu interconnections
describe anomalous nerve crossovers that can lead to more or less paralysis than expected for median and ulnar
nerve insults (41,42,43,44). In the Martin-Gruber anastomosis, ulnar intrinsic nerve fascicles are carried by the
median nerve, often as part of its anterior interosseous
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branch, into the target muscles in the hand causing a high median nerve palsy to present more like a combined
median-ulnar nerve palsy in the hand. In the case of the Riche-Cannieu anastomosis, thenar intrinsic nerve
fascicles are carried into the hand with the ulnar nerve; thus, individuals with median nerve damage present with
retained thenar intrinsic muscle function. Electrophysiologic studies can help elucidate such interconnections
when presented with an individual with a confusing presentation.
FIGURE 17-5 A,B: These clinical photographs demonstrate thenar opposition, a combination of palmar
abduction and circumduction that creates an expanse between the pulps of the thumb and remaining fingers.
This position is ideal for stable grasp of large objects especially.
Technique
Low Median Nerve Palsy: Opponensplasty (Fig. 17-6A-G) The described technique uses the ring finger FDS
as the donor motor, the APB tendon as the recipient, and a vector of force from the level of the pisiform to create
the circumduction moment (21,22,27,45).
An oblique incision is made over the ring finger A1 pulley between the distal palmar and MCP joint creases (Fig.
17-6A,B). The A1 pulley is incised longitudinally, and the FDS tendon is isolated and separated from the FDP
tendon (Fig. 17-6C). The ring finger is flexed, and the FDS tendon is divided transversely distal to its bifurcation.
The tails of the FDS tendon inserting onto the middle phalanx are left behind to adhere to the floor of the tendon
sheath and prevent PIP joint hyperextension.
A second longitudinal incision is now made along the radial margin of the thumb MCP joint long enough to
expose the desired insertion site(s) (Fig. 17-6B). In most cases, where radial innervation is intact, the APB
insertion will be the recipient. In some cases, where there may be need for simultaneous thumb MCP extension,
an additional recipient will be the extensor pollicis brevis insertion/dorsal MCP capsule. The surgeon should
mind the dorsal radial sensory nerve to the thumb in this exposure.
A third incision around the wrist creases is made in the region of the FCU tendon insertion into the pisiform to
create the vector of pull (Fig. 17-6B). The FCU and the ring finger FDS tendons are exposed while ulnar
neurovascular structures are protected. The radial half of the FCU tendon is divided transversely approximately
4 cm proximal to its insertion on the pisiform and mobilized creating a distally based tendon strip (Fig. 17-6D).
This FCU tendon strip is looped distally and passed through the distal portion of the FCU near the pisiform
insertion and secured with nonabsorbable
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sutures, thus creating a new pulley for the donor muscle (Fig. 17-6D). The ring finger FDS tendon is identified in
the same volar/ulnar wound, pulled into the proximal wound, and “threaded” through the FCU loop (Fig. 17-6E).
A subcutaneous tunnel is created between this wound and the radial thumb wound superficial to the palmar
aponeurosis (Fig. 17-6F). The donor tendon is routed through the pulley and into the radial thumb incision.
FIGURE 17-6 These illustrations and clinical photographs demonstrate the technique of opponensplasty using
the FDS of the ring finger as a donor motor. A: This illustration demonstrates the overall procedure and the
location of the surgical exposures to complete the procedure. B: This clinical photograph demonstrates the three
incisions required to complete the FDS opponensplasty. This patient underwent a simultaneous thumb
adductorplasty, and thus, the thumb MCP is stabilized by a pin not usually necessary.
FIGURE 17-6 (Continued ) C: The FDS of the ring finger is harvested at the level of the distal palm through any
type of oblique approach, and the FDS is confirmed and mobilized prior to its transection. D: A second exposure
is made along the FCU insertion into the pisiform allowing for manipulation of the distal 4 to 6 cm of the tendon. A
tendon loop using the FCU is fashioned and acts as the pulley for the FDS ring that has now been brought into
this more proximal wound. E: The FDS ring is threaded through the FCU loop, which should provide enough
space for the donor muscle to easily glide. F: A capacious subcutaneous tunnel is now created from the radial
thumb excision where the site of the recipient is, toward the wrist wound. Here, the FDS ring is passed distally
into the recipient site. G: The FDS ring is coapted into the APB tendon insertion to complete the tendon transfer.
(Clinical photographs in Figure 17-6B through F are courtesy of Joshua Ratner, MD, and Scott Kozin, MD.)
(From Berger RA, Weiss A-PC: Hand surgery. Philadelphia, PA: Lippincott Williams & Wilkins, 2003.)
Several options for attachment of the tendon transfer have been described with more dorsal insertions
enhancing pronation and more radial attachments yielding greater abduction (31,46). The exact position for
insertion depends upon the needs of the patient and his or her thumb determined prior to surgery, but is typically
the tendon of the APB (Fig. 17-6G).
Regardless of the chosen insertion site, correct tensioning is imperative to achieve an optimal result. Tensioning
is set with the wrist in neutral to slight extension and the thumb resting against the lateral aspect of the radial
side of the index finger about its distal interphalangeal (DIP) joint. The estimated resting length of the donor is
based upon its natural elasticity, allowing it to settle in its resting position. The result should be enhanced
opposition with progressive wrist extension and relaxation as the wrist flexes beyond neutral. After skin closure,
the thumb is immobilized in opposition and the wrist in slight extension keeping the coaptation without tension
while maintaining comfort for the individual.
High Median Nerve Palsy

OPPONENSPLASTY USING EIP (FIG. 17-7A,B) The EIP as a donor motor was initially described by Burkhalter
and is a fairly synergistic transfer (23,26). Although the EIP does not have the force of contraction of the FDS
ring, it is still greater than that of the APB and can serve as an appropriate donor muscle. This procedure
involves routing the EIP from its normal insertion into the extensor hood of the index MCP joint around the ulnar
side of the wrist toward the APB insertion in the thumb.
The EIP is first harvested via a small approach in line with Langer's lines at the level of the index extensor hood
(Fig. 17-7A). The EIP is taken with some of the hood to maximize length, and the hood is repaired with
nonabsorbable suture. A second longitudinal incision is created proximal to
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the extensor retinaculum and more toward the ulnar side of the forearm where the EIP is identified and mobilized
into (Fig. 17-7B). The distal muscle belly within the tendons of the fourth extensor compartment often identifies
the EIP. It is mobilized from soft-tissue attachments to create straight line of pull from its origin. A third oblique or
zigzag incision is now created along the palmar ulnar base of the wrist in the vicinity of the pisiform, and the EIP
is drawn into this wound via a subcutaneous tunnel from the second exposure (Fig. 17-7B). Finally, a radial
midaxial incision is created along the thumb MCP joint, and the APB insertion is identified while protecting the
dorsal radial sensory nerve. A tunnel is created superficial to the palmar aponeurosis, and the EIP is brought into
the thumb incision and coapted into the APB (Fig. 17-7B). Tension is set with the wrist in 10 degrees of
extension, the thumb opposed against the side of the index finger, and the EIP in its natural elastic resting
position. This position is the position of splinting/casting and may include other fingers depending upon other
simultaneous transfers performed.
FIGURE 17-7 A: This illustration demonstrates the dorsal incisions for the EIP opponensplasty. The EIP is
initially harvested at its insertion into the index extensor hood. It is then mobilized proximally on the ulnar side of
the forearm proximal to the extensor retinaculum through a separate incision. B: A third volar/ulnar incision takes
the EIP to the level of the ulnar base of the palm to create the vector of pull, and then finally, the tendon is
passed through a tunnel superficial to the palmar aponeurosis to the fourth exposure at the level of the radial
thumb for recipient coaptation. (From Berger RA, Weiss A-PC: Hand surgery. Philadelphia, PA: Lippincott
Williams & Wilkins, 2003.)
FPL RESTORATION USING THE BRACHIORADIALIS (FIG. 17-8A-D) Utilization of the BR for FPL restoration
has a long history (47,48). The BR is a secondary elbow flexor that is a very useful donor muscle provided the
surgeon understands that much of its potential excursion is tied up in intermuscular fascial connections
throughout the forearm; therefore, the surgeon must be prepared
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to plan surgical approaches that allow for its more extensive mobilization requirements despite its tendon's very
close proximity to the FPL tendon in the forearm (2,32,49). The BR also possesses excellent potential
contraction force, and so it is very suitable to help restore lateral pinch strength (50).
FIGURE 17-8 These clinical photographs demonstrate the salient features of the BR to FPL transfer. A: The BR
is detached from its insertion onto the radial styloid just deep to the outcroppers. The Freer elevator points to the
BR tendon, and the branches of the superficial sensory radial nerve are nearby and should be identified and
protected. B,C: In order to increase the BR excursion, it must be freed of surrounding fascial attachments from
the distal tendon proximally into the area of the mobile wad. The photographs demonstrate about 3.5 cm of
excursion and suggest that more release is required. D: The FPL is identified in the distal forearm, and the
transfer is completed using a Pulvertaft weave.
The surgical exposure should access the BR into the area of the proximal half of the forearm. Assuming
simultaneous side-to-side FDP transfers are planned to restore index/long FDP function, a single longitudinal
radial forearm incision should suffice with the proximal wrist crease serving as the distal margin. The radial artery
and venae comitantes, branches of the lateral antebrachial cutaneous nerve, and superficial sensory radial
nerve should all be protected. The BR is identified on the radial side of the forearm, lateral to the radial artery, by
mobilizing the radial aspect of the exposure. The BR is released from its insertion on the radial metaphysis by
mobilizing the APL/EPB muscles covering it (Fig. 17-8A). The tendon is then freed of surrounding tissue from
distal to proximal until the muscle belly is also released and at least 4 to 5 cm of passive excursion can be
obtained (Fig. 17-8B,C). The tendon is now brought deep to the radial artery and venae comitantes and coapted
into the FPL (Fig. 17-8D). The authors choose to set tension with the elbow at 90 degrees of flexion, the wrist in
slight extension, and the thumb resting against the side of the index finger in opposition. As the BR crosses the
elbow joint, its resting tension, and thus sarcomere length, is influenced by the position of the elbow as much as
the wrist or thumb. A transfer set in elbow extension may result in relative weakness as the elbow becomes
flexed, and a transfer set in full flexion may result in too much tension, making release difficult in elbow extension
(4,12).
RESTORATION OF INDEX/LONG FINGER FLEXION Effective lateral pinch and thumb/index dexterity depends
upon sufficient finger flexion. Consideration for also restoring long finger flexion depends upon the individual, and
the transfers work for both or either. We describe the side-to-side FDP transfer, but the reader is referred to
articles on an ECRL-mediated active transfer if independent index flexion is required by the individual (39,40).
We believe that strength is not as critical to index function as positioning, and generally perform the side-to-side
transfer in most circumstances.
As just described in transfers for thumb flexion, a longitudinal radial-sided forearm incision is sufficient exposure
for this tendon transfer. The radial artery, branches of the lateral antebrachial cutaneous nerve, and median
nerve need accounting. Sweeping the superficial flexors gently with a deep retractor exposes the deep flexor
tendons and, particularly, the FDP tendons. Similarly to an extensor digitorum communis (EDC) synchronization
described in the section discussing radial nerve transfers, this transfer is achieved using three horizontal
mattress sutures starting proximally to allow for tension adjustments as the surgeon proceeds with the next,
distal, mattress. We prefer a compromise between a standard cascade and complete flexion symmetry, but the
surgeon can decide the degree of index/long flexion with regard to the ring/small FDP. An assistant maintains
finger position while redundant tension is addressed by “pulling” all the tendons proximally. The surgeon
envisions where the three horizontal mattress sutures will be placed such that they do not enter the carpal tunnel
in full digital extension. The most proximal location is now secured and tension tested with simple wrist
tenodesis. The next two more distally placed sutures allow the surgeon to adjust the desired tension between the
FDP tendons as needed.
Pearls and Pitfalls

In opposition transfers where the FDS is the donor muscle, leave part of the insertion intact when harvesting
to help prevent postoperative PIP hyperextension deformity.
When using the FCU loop, ensure that the donor muscle/tendon freely moves and is not constricted.
Pay attention to the position of the elbow when setting tension using the BR as a donor muscle.
A short arm thumb spica cast with the thumb in opposition is maintained for approximately 3 weeks, at which
point it is exchanged for a short arm thumb spica, again with the thumb in opposition. If a BR transfer is
performed, then immobilization needs to extend above the elbow. For FDP restoration, a dorsal blocking splint is
incorporated so that some early motion is allowed. Formal physiotherapy commences with active range of motion
and learning how to fire the transfer several times a day out of the splint using any variety of biofeedback
techniques. By the 6th week, depending upon progress, the individual is taught to position the thumb for
functional activities without necessarily using significant strength to begin the process of learning his or her
transfer. The splint is then discontinued as strengthening exercises begin, and the individual progresses in
functional tasks, such as large-object acquisition and manipulation proceed to help the individual learn his or her
transfer and learn to adapt to any sensory deficits as well. After approximately 8 to 12 weeks, and depending
upon the individual's progress, therapy is discontinued as he or she completes the transition to normal activities
of daily living.
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Complications
As with many tendon transfer surgeries, scarring, adhesion formation, inappropriate tensioning, and joint
contracture lead to worse than expected surgical outcomes. Specific complications can arise with the
various transfers:
Swan neck deformity can occur after FDS transfer. Donation of FDS can lead to bowstringing and PIP
contracture or hypermobility (51). This is the rationale behind transecting the FDS just after the origin of
Camper's chiasm, leaving the insertional tails to scar and prevent hyperextension deformities.
Ring finger FDS opponensplasty can produce superficial radial nerve compression. Superficial radial
nerve injury can also occur in Camitz opposition transfer (52).
Ulnar nerve palsy can result from compression following EIP opposition transfer superficial to the ulnar
nerve (53).
Results
Regardless of the operative technique, overall restoration of thumb opposition remains favorable.
In cadaveric biomechanical testing, a volar radial tendon insertion at the APB was more effective than
was a dorsal ulnar insertion at the proximal phalanx in recreating thumb opposition independent of the
opposition transfer procedure (22).
FDS opponensplasty transfers met with good results. The Bunnell opposition transfer affords excellent
palmar abduction (54).
The ADM opposplasty can be difficult technically as extensive dissection of the muscle is required to gain
sufficient “reach” to the thumb (55).
EIP opposition transfer yields overall favorable results. Excursion of the EIP is in phase with wrist
tenodesis. However, EIP motor donation should not be used if there is stiffness within the wrist and/or
thumb (36).
The PL opponensplasty produces reliable abduction and can be sacrificed without noticeable deficit
(30,52).
Restoration of digit flexion via BR to FPL and ECRL to FDP tendon transfers result in good range of
motion and functional restoration of grip strength (40).
ULNAR NERVE PALSY

Indications (Fig. 17-9A-D)
The location of the ulnar nerve lesion with respect to the elbow and forearm determines the extent of
impairments an individual would suffer from. Loss of all intrinsic muscle function saves the median
innervated index and long lumbricals, and thenar intrinsics leave individuals with significant loss of hand
dexterity and strong thenar pinch (56,57,58). The loss of all digital intrinsic function for the ring and small
fingers creates inefficient grasp patterns as the fingers curl into flexion via the interphalangeal joints instead
of flexing at the MCP joint too. Loss of efficient digital adduction and abduction creates positional
deficiencies that affect dexterous pinch and small-object manipulation (Fig. 17-9B) (59,60). And while thenar
intrinsic function allows an individual's thumb to reach around a larger object for pinch and grasp, the
absence of the AdP requires substitution patterns for pinch strength that are weaker and less effective (Fig.
17-9C,D) (61,62). In more proximally located lesions, there is additional loss of small and ringer DIP flexion
and loss of FCU-mediated wrist function (affecting dart thrower's motion and mechanics?) especially if the
lesion is proximal to the elbow. Finally, the individual lacks sensation in the small finger ray and the ulnar
half of the ring finger ray; the degree of dorsal loss of ulnar-sided sensation depends upon the location of
the lesion with respect to the dorsal ulnar sensory nerve branch.
The Martin-Gruber and Riche-Cannieu interconnections described earlier in regard to median nerve palsy
can certainly influence the presentation of an individual with ulnar nerve damage (41,42,43,44). Individuals
with a Martin-Gruber anastomosis and a “low” ulnar nerve palsy may present with minimal disability as
many of the intrinsics are still innervated by branches of the median nerve. Absence of small/ring FDP and
possible FCU would still exist in high ulnar nerve palsies. An individual with a Riche-Cannieu anastomosis
and ulnar nerve palsy would present with considerable disability as the thenar intrinsics and index/long
lumbricals would also be paralyzed, rendering a presentation of low median-ulnar combined nerve palsy
despite damage to only one nerve.
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FIGURE 17-9 The clinical manifestations of ulnar nerve palsy. A: Clawing of the small and ring fingers due
to the absent function of the intrinsic muscles. The index and long fingers are without clawing due to the
integrity of the lumbrical muscles. This hand also demonstrates intrinsic and thumb web space atrophy. B:
The flattening of the palm occurs from the absence if interossei function that helps create the “cup” shape
of the palm. Hypothenar atrophy is also evident. Wartenberg's sign is evident in the abduction of the small
finger. C: Froment's sign occurs from the absent function of the AdP and first dorsal interosseous. D:
Jeanne's sign refers to MCP hyperextension of the thumb during pinch secondary to weakened FBP
function combined with absent functioning of the AdP and first dorsal interosseous.
Nowhere is preoperative evaluation important than in addressing an individual with ulnar nerve palsy given the
number of discrete impairments associated with loss of most of the hand's intrinsic function. The loss of strength
and dexterity, the potential development of contractures, along with alterations in hand morphology make a
daunting list for the reconstructive surgeon. Many of the problems are fortunately surmountable or do not rise to
the level of significant disability, that is, loss of small finger adduction (Wartenberg's sign). An individual's age,
handedness, occupation, hobbies, and the like will ultimately determine which components of ulnar nerve palsy
require consideration for reconstruction. As mentioned earlier, good communication between the surgeon and
individual is critical, and listed are some of the particular issues individuals with ulnar nerve palsy may face:
Lateral pinch Compromised from the loss of the AdP and first dorsal interosseous (FDI) muscles and the
relative weakening of the FPB. The compensations mediated by median innervated muscles leads to the
physical signs encountered during examination (Froment's sign, Jeanne's sign; Fig. 17-9C,D). The
compensation may very well be sufficient for certain people, but just as many will note this to be a troubling
part of their nerve palsy. There are a variety of surgical strategies.
Thumb adductorplasties utilizing either the ECRB or ECRL (63,64,65). The FDS ring finger has also been
used, but should be avoided in high ulnar nerve palsy if there is already weak or absent FDP ring finger
flexion (Fig. 17-10) (66). This is an effective transfer, and the authors
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prefer to use the ECRL as the donor motor in order to maintain balanced wrist extension. The FDS ring is a
good option if the surgeon is planning digital reconstruction using a wrist extensor (Fig. 17-10D).
Index abductorplasties utilizing the APL or EPB (1,62,64,67). This option may be relevant if the surgeon is
planning digital intrinsic reconstruction using a wrist extensor (Fig. 17-11).
Arthrodesis of the thumb MCP (68).
Clawing Contractures, initially supple, develop from loss of intrinsic muscles despite the presence of extrinsic
flexors and extensors. The median innervated lumbrical muscles maintain enough intrinsic function to the
index/long that the clawing affects the ring/small fingers (Papal sign) (Fig. 17-9A). The inefficient grasp pattern
that results from finger flexion initiating at the interphalangeal joints instead of the MCP joints creates
problems with large-object grasp and strength (56,57,58). The goal of these reconstructions is to create an
MCP flexion moment to ease in large-object manipulation and overall dexterity. Elegant tendon transfers are
also designed to address the associated proximal interphalangeal joint extensor lags left from the loss of the
intrinsic function to the PIP joint. Most transfers tend to address just the ring and small finger; however, it is
probably preferable to think of these procedures as interosseous reconstructions; therefore, consideration
should be given to reconstructing MCP flexion for all four fingers (58).
Static intrinsic-plasties as originally described by Zancolli create static MCP flexion through a capsulodesis
(Fig. 17-12) (69,70,71).
Dynamic intrinsic-plasties use tendon transfers to restore active MCP flexion and, if need be, active PIP
extension depending upon the actual insertion site of the donor motor. The two commonly considered donor
motors are parts of the FDS and the ECRL. The choice may very well depend upon whether a wrist
extensor-mediated thumb adductorplasty is already a part of the reconstructive plan (Fig. 17-13)
(46,58,72,73,74).
Small finger adduction deformity (Wartenberg's sign) (Fig. 17-9B) Some individuals find the inability to adduct
their small fingers a troubling nuisance. A static transfer using the EDM or an active transfer using the EIP has
been described (75,76,77,78).
Absent ring/small DIP flexion (high ulnar nerve palsy) If absent DIP flexion of the small and ring fingers
creates issues with object manipulation, then side-to-side transfers using ring FDP are performed; however,
restoration of lost strength is not the specific goal with this transfer.
FIGURE 17-10 Creating thumb adduction to augment pinch can be achieved using a wrist extensor as a donor
motor. A: This clinical photograph demonstrates a method to lengthen a tendon to bridge a defect without
utilizing a donor tendon graft. A long tendon can be split longitudinally leaving its distal aspect whole (distally
based split). This distal aspect is augmented with suture to maintain integrity. Alternatively, if the tendon diameter
is deemed sufficient, the entire tendon can be split longitudinally leaving one limb intact with the muscle, and the
other as a donor tendon graft (Courtesy of Joshua Ratner, MD.) B: This illustration outlines the thumb
adductorplasty using the ECRL and a free tendon graft. (From Berger RA, Weiss A-PC: Hand surgery.
Philadelphia, PA: Lippincott Williams & Wilkins, 2003.) Three to four incisions over the dorsum of the
hand/forearm and the dorsoulnar thumb to mobilize the wrist extensor create a transverse vector and attach it
into the ulnar aspect of the thumb. C: Clinical photograph illustrating the surgical approaches. This patient, with
Charcot-Marie-Tooth disease, underwent a simultaneous opponensplasty, and thus, a radial thumb incision is
also seen. D: This illustration demonstrates utilizing the FDS ring as a thumb adductor by releasing it and
bringing it across the palm toward the ulnar aspect of the thumb. (From Berger RA, Weiss A-PC: Hand surgery.
FIGURE 17-11 This illustration demonstrates the features of the APL-mediated index abductorplasty. A free
tendon graft is required to complete the procedure, which can be incorporated into the operative strategy to
address lateral pinch as required by an individual's particular needs. (From Berger RA, Weiss A-PC: Hand
surgery. Philadelphia, PA: Lippincott Williams & Wilkins, 2003.)
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FIGURE 17-12 These clinical photographs and illustrations demonstrate the static intrinsicplasty described by
Zancolli. A: This photograph demonstrates an individual with clawing of all fingers secondary to a low combined
median-ulnar nerve palsy. B: With the wrist in extension, the interphalangeal joint flexes, but the MCP joints do
not secondary to intrinsic imbalance. C: Each finger is approached through an oblique or Bruner incision
centered about the MCP joint. D: The FDS is isolated and transected distal to the A1 pulley, leaving two slips. E:
This illustration outlines wrapping the FDS around the A1 pulley and suturing it back to itself under tension, thus
“lassoing” the A1 pulley and bringing the MCP into flexion. F: This former step is demonstrated here. G: Note
the difference in static posture of the hand with the wrist in extension comparted to (B) where now the MCPs are
in a more functional flexed position. (From Berger RA, Weiss A-PC: Hand surgery. Philadelphia, PA: Lippincott
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FIGURE 17-13 This illustration demonstrates the salient features other the ECRL-mediated intrinsicplasty
described in detail in the text. The ECRL, aided by tendon grafts, is passed from dorsal to the volar wrist and
hand compartments and then inserted into the desired intrinsic recipient sites. (Modified from Berger RA, Weiss
A-PC: Hand surgery. Philadelphia, PA: Lippincott Williams & Wilkins, 2003.)
Technique
Thumb Adductorplasty (Fig. 17-10A-C) This technique traditionally utilizes an autologous tendon graft to
bridge a defect between the donor muscle and the recipient, as can the intrinsic-plasties; therefore, the surgeon
should consider the entire operative plan incorporating the need for tendon grafts or consider technical
alternatives that could limit the use of donor tendons to bridge defects. A technique to increase the length
involves longitudinally incising the tendon as if performing a Z-lengthening, but releasing one-half proximally and
leaving the tendon together distally to create a “distally” based tendon extension secured at that distal site by
nonabsorbable suture (Fig. 17-10A) (24,79). This latter technical modification of tendon lengthening is useful
here.
While the original description of this transfer describes the ECRB as the donor motor, we prefer to use the ECRL
and keep the ECRB intact for more balanced wrist extension (63,65). The following description applies to either
wrist extensor. A series of 2 transverse incisions are made over the course of the ECRL: one near its insertion
wide enough to gain access around the ulnar aspect of the long finger metacarpal and one proximal to the
extensor retinaculum, and the ECRL is detached and mobilized proximally. A third more proximal incision can be
utilized to mobilize muscle as needed. The recipient site is exposed via an incision along the ulnar aspect of the
thumb large enough to access the insertion of the AdP (Fig. 17-10B,C).
Preparation for recipient attachment depends on the use of a tendon graft. The tendon graft, if used, is now
secured to the AdP tendon or directly into the proximal aspect of the thumb's proximal phalanx through a drill
hole. A curved clamp is now passed from most distal transverse incision, around the long metacarpal, palmar to
the AdP, and directed to the thumb wound. The tendon graft is now brought into the dorsal hand wound and
coapted. This coaptation area should be set so that it does not “rub” around the metacarpal during activation.
Tension is set with the wrist in neutral to 10 degrees of extension and the thumb resting against the radial aspect
of the index near the PIP/P2 area. If the ECRL tendon is lengthened instead, the author's preference, it is passed
into the thumb wound by a clamp that starts at the thumb wound and heads ulnarly to the long metacarpal base
along the palmar surface of the AdP where the lengthened tendon is grasped from the dorsal side of the hand.
The tendon is coapted into the ulnar base of the proximal phalange of the thumb or the AdP insertion with
tension set as with the tendon graft. The arm is immobilized from above the elbow with the wrist in slight
extension and the thumb in opposition.
Digital Intrinsicplasty Despite the clawing present in only the ring and small fingers, intrinsicplasty should be
thought of as an interosseous reconstruction, and so consideration should be given to restoring all four fingers.
The Bouvier's test, which determines the extrinsic extensor's ability to extend the PIP joint, helps the surgeon
determine whether the lateral band/PIP area should be the insertional site (80). A positive test, indicating the
extrinsic extensors sufficiently extend the
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PIP joints when the MCPs are held flexed, suggests that a tendon transfer need only restore MCP flexion. This is
achieved by inserting the donor tendon into the A1 or A2 pulley depending upon which produces enough MCP
flexion, or even into the proximal phalange through a bone tunnel (Fig. 17-14A,B). On the other hand, a negative
Bouvier's test, indicated by an extensor lag, suggests the recipient site should include the lateral bands or dorsal
PIP in order to create both MCP flexion and PIP extension if desired (Fig. 17-14C).
FIGURE 17-14 Illustrations of recipient options for intrinsic reconstruction of the fingers. In the presence of a
positive Bouvier's test, the recipient site can be either the (A) A1 or A2 pulley or the (B) proximal phalange itself
via a bone tunnel. In the presence of a negative Bouvier's maneuver, setting the recipient as the lateral
band/extensor (C) creates the potential for interphalangeal extension associated with simultaneous MCP flexion.
(From Berger RA, Weiss A-PC: Hand surgery. Philadelphia, PA: Lippincott Williams & Wilkins, 2003.)
ECRL Intrinsicplasty (1,56,58) (Fig. 17-13) By adding a donor muscle to the process of MCP flexion, the ECRL
has the potential to bring added strength to the hand, although to what extent and benefit is remains unproven.
The ECRB is preserved. This transfer also requires a tendon graft with four “tails” secured as a continuation of
the ECRL tendon. The PL is the most commonly used source when available.
The ECRL insertion is approached through a small transverse incision and released. A second transversely
oriented exposure proximally and radially in the forearm is created at the level of its myotendinous junction, and
the tendon is brought into this wound while protecting the superficial sensory radial nerve, the ECRB and the
BR. The tendon graft is now secured into the ECRL tendon, and four “tails” are created. A third transverse
incision is made along the area of the proximal wrist crease, volarly, and the ECRL/tails are passed through a
subcutaneous tunnel into this wound. A fourth incision in the midpalm is created with care taken to identify the
superficial palmar arch and median nerve branches. This exposure will serve as the staging area for passing the
four tails into each of the four digits. The ECRL/tails are now passed into the midpalm through the carpal tunnel.
Insertion of the tails into their recipient site depends upon whether the Bouvier's maneuver is positive (A1/A2
pulley insertion) or negative (lateral band or dorsal PIP insertion). For A1/A2 pulley insertions, volar Bruner
extensions from the midpalmar wound are used to pass each tail into its respective digit in preparation for
insertion. The tails are passed around the desired pulley deep to distal and then passed superficial to proximal to
“lasso” the pulley. When PIP extension is desired, then a new set of radial-sided incisions into the small, ring,
and long fingers are used to expose their respective radial lateral bands, while an ulnar-sided incision is used to
approach the index finger in order to avoid creating an unwanted index abduction moment. Each tail is passed
from the midpalm wound into the respective digital wound with the MCP flexed and with the tails passing volar to
the intermetacarpal ligaments. The tails are woven into their respective lateral bands. Alternatively, the tendons
can be attached into the central slip.
Tension is now set with the wrist in neutral position, and the MCPs in neutral to 10 degrees of flexion with the
ECRL at its estimated resting length. The surgeon should seek to recreate a normal flexion cascade and should
error to the side of parallel flexion to avoid an exaggerated cascade. Wrist tenodesis should confirm MCP flexion
as the wrist moves into extension occurring prior to interphalangeal joint flexion. If the tendon tails are inserted
into the lateral bands, there should be evidence of interphalangeal extension as the MCPs flex.
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FDS Intrinsicplasty (46,72,73) (Fig. 17-15) The FDS ring or long is the chosen donor motor. This technique
reroutes a muscle already in use for grasp, so there is no expectation of increased strength except for that
provided by a more efficient grasp pattern. It is an in-phase transfer and certainly the ideal choice when a wrist
extension-mediated thumb adductorplasty is planned. And its location requires less exposures and dissection as
the donor is already within the palm. If Bouvier's maneuver is positive, then another advantage of using the FDS
is that a tendon graft may be unnecessary.
The donor tendon is harvested through a volar Bruner incision centered about the MCP joint of the donor
“finger.” The FDS is specifically transected just distal to the start of Camper's chiasm to preserve enough
insertion so that it scars and prevents a PIP hyperextension deformity. The tendon is split, and then again to
create four tails long enough to easily reach each recipient site. Bruner approaches expose the remaining three
digits, and the A2 pulley is isolated. As with the ECRL-intrinsicplasty, each FDS tail is lassoed around the A1/A2
pulley and secured with wrist in neutral position and the MCPs in neutral to 10 degrees of flexion. As with the
ECRLmediated transfer, setting the tension to restore the flexion cascade requires careful attention and
patience.
FIGURE 17-15 This illustration outlines the FDS-mediated instrinsicplasty, a technically simpler approach to
creating dynamic intrinsic function, but without the potential added strength associated with “adding” a motor to
the fingers. (From Berger RA, Weiss A-PC: Hand surgery. Philadelphia, PA: Lippincott Williams & Wilkins, 2003.)
Zancolli Intrinsicplasty (74) (Fig. 17-12A-G) A straightforward technique to reconstruct MCP flexion was
described by Eduardo Zancolli and is an effective solution when there is already good digital balance, and
clawing is relatively mild. This technique uses the active FDS in each finger as its own transfer. The FDS to the
finger is harvested as described for the FDSintrinsicplasty and simply routed around the A1 pulley (or A2 if
creates better MCP flexion). He described this technique for just the ring and small, but can be applied to all.
Digital flexion is now activated through the MCP and DIP joint, instead of the PIP and DIP joint. In individuals with
a positive Bouvier's test and mild clawing, this technique is very effective and requires neither tendon grafts nor
the need to create separate tendon tails.
SMALL FINGER ADDUCTORPLASTY While a tenodesis using a distally based strip of the extensor digit minimi
can correct the static deformity, we favor an active transfer when possible that also maintains small finger
abduction. The selected donor muscle is the EIP (75,76,77,78).
The EIP is harvested at its insertion into the index extensor hood through a small incision in line with Langer's
lines. The EIP is harvested in continuity with a slip of the extensor hood (length is important to this transfer). The
defect in the hood is repaired with nonabsorbable suture. A second transverse incision is created at the distal
margin of the fourth extensor compartment, and the EIP is brought proximally out of this wound. A third incision is
created along the dorsoradial aspect of
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the small finger at and distal to the MCP joint. The EIP is now passed into this wound volar to the
intermetacarpal ligament and woven into the radial lateral band. The tension is set with wrist in neutral and the
small finger MCP and PIP in slight flexion.
SMALL-RING FDP RESTORATION In the setting of high ulnar nerve palsy, and when indicated, restoring small
and ring finger DIP flexion is achieved using a side-to-side transfer with the long finger FDP as the donor. The
index FDP is preserved to maintain independent index finger flexion. The FDP tendons are exposed in the
forearm through a longitudinal incision. Once the median nerve and FDS tendons are protected, the four FDP
tendons are identified. The small, ring, and long FDP tendons are sewn together using a series of three
horizontal mattress nonabsorbable sutures. Tension is set such that the three fingers will flex simultaneously and
parallel, as opposed to the normal cascade of flexion. This “reverse” cascade is aided with an assistant holding
the three fingers in maximal flexion. The first suture placed should be in the proximal position, so that by using
wrist tenodesis, adjustments in tension are easily achieved with the next most distal horizontal mattress.
Pearls and Pitfalls

When performing a wrist extensor-mediated thumb adductorplasty, the surgeon should ensure that the
coaptation between the tendon graft and the extensor tendon, or the juncture where the extensor tendon was
lengthened, does not catch around the area of the long metacarpal.
Setting tension between either the ring/small or all four fingers when performing intrinsicplasty is critical. Small,
fine, hemostats can clamp each “tail” in the estimated tension while using wrist tenodesis to test for the
recreation of the normal flexion cascade. In this way, the tension on each finger can be individually adjusted
prior to setting the coaptation with sutures.
Keeping the MCPs flexed allows for passage of donor tendons volar to the intermetacarpal ligaments as is
needed for a wrist extensor-mediated intrinsicplasty and small finger adductorplasty.
Immobilization to protect the transfers continues for 3 weeks postoperatively, and then gentle mobilization with a
rehabilitation splint is begun. The splint is weaned at approximately 6 weeks to part time and then at night at
about 8 weeks. Exercises reinforcing biofeedback and tendon transfer activation are initiated at 3 weeks with
active range of motion several times daily while maintaining the splint full-time. At 6 weeks, the splint can be
weaned to nighttime wear provided patient compliance. At 8 weeks, exercises to build strength are instituted as
transfer activation exercises continue. At this time, functional task exercise progresses to help individuals learn
their transfer. Passive motion and splinting is done to correct any developing contractures. Strengthening,
functional task training, and dexterity training continue, and all splinting can be stopped by 10 to 12 weeks. By
this time, individuals should be able to start transitioning to home programs and away from formal therapy visits.
Complications
Due to the complexity of ulnar nerve injuries and the intensive postoperative rehabilitation to restore intrinsic
hand function, ulnar nerve palsies create complicated reconstructive and rehabilitative challenges. Patient
selection is paramount to optimize functional outcomes. Cortical reeducation to perform the compounded
complex motions of lateral pinch and correct claw deformity and small finger adduction after multiple transfer
procedures requires lengthy and intensive therapy. The use of appropriate motors is important to prevent
compounding deficits. For instance, harvesting the FCR in high ulnar nerve injury will result in wrist
weakness due to FCU palsy. Transfers must also not be set too tightly as to create joint contractures.
Donor motors must also be strong enough to produce the expected strength gains (58).
Specific complications can arise with the various transfers:
Swan neck deformity can result from FDS donor and lateral band insertion. FDS transfer should therefore
be used with caution in patients with hypermobile joints (58).
Volarly routed ECRL intrinsicplasty scarring can occur due to the use of multiple incisions and long
tendon grafts (56,81).
Static intrinsicplasties stretch over time and can lead to reduced grip strength (69).
Intersection syndrome can develop at graft/wrist extensor interface with thumb adductionplasty (64).
Bowstringing of the FDS adductorplasty can develop between the palmar aponeurotic pulley and thumb
(77).
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Results
Restoration of lateral pinch has favorable outcomes in recent literature.
Strength of lateral pinch is dependent on the donor motor. ECRL to AdP with APL to FDI improves lateral
pinch strength greater than does APL or EPB to FDI alone (64).
Return of pinch strength has been shown to be greater than 70% of the contralateral side (64,67).
Treatment of clawing and interosseous function seems to fare better with dynamic rather than static
techniques.
Static procedures, such as the Zancolli static tenodesis, have a propensity to stretch over time (69).
Even though dynamic procedures such as the FDS intrinsicplasty do correct clawing and improve digital
dexterity, functional gains in strength are not realized. Better strength gains are achieved with a volarly
routed wrist extensor motor donor (82).
The Zancolli “lasso” procedure and the ECRL 4-tail dynamic intrinsicplasties restore grip strength more
effectively than does the FDS 4-tail intrinsicplasty. The FDS 4-tail intrinsicplasty, on the other hand,
corrects claw hand deformity more effectively than do the Zancolli “lasso” and ECRL-tail intrinsicplasty,
especially in long-standing paralysis with extensor apparatus elongation (83).
Correction of Wartenberg's sign with active adduction of the small finger has favorable results with use of
EIP donor. Patients were able to maintain small finger adduction with favorable and no extension lag to the
index finger (77).
RADIAL NERVE PALSY

Indications
As with the median and ulnar nerves, the extent of disability associated with a radial nerve palsy, and the
subsequent extent of reconstruction, depends upon the location of the damage. In the case of the radial
nerve, the location of damage with respect to the elbow is the discriminator. The radial nerve innervates all
of the wrist extensors, the supinator muscle, all of the extrinsic digital extensors, and thumb abductors.
There is substantial difficulty with all pinch and grasp function secondary to loss of wrist extension and loss
of the ability to actively release objects (Fig. 17-16). Distal to the elbow, innervation to the BR and ECRL is
preserved, and so is functional wrist extension, albeit with radial deviation. Patients with a lower radial
nerve palsy, that is PIN palsy, will retain a reasonable stable position for pinch, but still have to rely on wrist
flexion tenodesis to let objects out of their grasp. Radial nerve palsies, unless associated with a shoulder
girdle-level injury, generally spare the triceps. Sensory loss, present in high radial nerve damage, resides
along the dorsal thumb index area in the distribution of the superficial sensory radial nerve and rarely
creates problems for the individual with regard to function.
Primary indications for tendon transfers remain the same as with other nerve palsies with one major
exception, namely, the provision of early wrist stability. The wrist drop can be addressed through
appropriate splinting, but there are situations and preferences where individuals need or prefer to be as
brace free as possible quickly. In such circumstances, an early wrist extension transfer is performed to
restore dynamic wrist stability even in circumstances where recovery of wrist extension is possible (84,85).
FIGURE 17-16 Clinical photograph of an individual with a high radial nerve palsy. This individual can
neither extend his wrist nor extend his fingers or thumb.
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The primary deficits that require the surgeon's attention include wrist drop (not present in PIN palsy), digital MCP
extension lags, and thumb extension lags (Fig. 17-16). While the supinator is denervated in these individuals, the
biceps more than takes care of active forearm supination. And despite loss of the abductor pollicis longus,
individuals will compensate.
Wrist extension The PT is the common choice for donor muscle to restore wrist extension in the setting of
radial nerve palsy. The recipient site is the ECRB to maintain a more balanced wrist extension. Inserting the
transfer into the ECRL creates too much radial deviation. This transfer retains some of the PT's pronation
moment, but does not affect the functioning of the PQ. There is some question as to whether there is any
functional implication from reducing the pronation moment from this transfer, but it has not been studied except
in the cadaver (86).
Finger MCP extension Traditional tendon transfer strategies fall into three groupings determined primarily by
the donor motor for finger extension. The three “classic” approaches are the Brand (FCR), Jones (FCU), and
modified Boyes (FDS) transfers (81,87,88,89,90).
Thumb extension Independent thumb extension can be restored using the PL when present. Alternatively,
thumb extension can be restored with finger extension together (91,92).
Increased understanding of wrist biomechanics has relevance to decision making when reconstructing wrist
extension in individuals with radial nerve palsy. Recent findings suggest that the wrist's true plane of motion is
extension/radial deviation to flexion/ulnar deviation, known as the “dart thrower's motion” (93,94). This more
“oblique” requirement is efficient with respect to carpal motion, and many tasks of varying demand levels are
performed along the path of radial extension to ulnar flexion. The Jones tendon transfers sacrifice the wrist
flexion/ulnar deviation moment produced by the FCU in order to activate finger extension. And while there is
currently an absence of data supporting the preservation of the dart thrower's motion when reconstruction wrist
motion in the setting of radial nerve palsy, the authors prefer using the FCR as the donor motor to restore finger
extension to preserve the function of the FCU (87,95). Our experience suggests difficulties with using the FDS as
the donor motor for digital extension, particularly with learning the transfer; thus, the FCU becomes the next
choice if there are circumstances that negate using the FCR as the donor motor. If the FCR is chosen for the
EDC motor, a single utilitarian curvilinear radial-sided incision can be used to perform all of the transfers. The
authors believe, however, that surgeons should have knowledge of the various techniques as there may be
occasion when they become the best choice for a particular individual.
Technique (Fig. 17-17A-C)

As mentioned earlier, the only difference in tendon transfer reconstruction between high radial nerve palsies and
low radial nerve palsies (PIN palsy) is the need to restore dynamic wrist stability with the former via a wrist
extension transfer. The entire reconstruction for radial nerve transfers can be achieved with a single extended
radial forearm incision (straight line or lazy-“S” shape) or via a combination of dorsal and volar incisions. The
authors prefer the single radial forearm approach with smaller additional exposures as called for (Fig. 17-17A,B).
The radial approach extends from the distal aspect of the mobile wad muscle bellies to the area of the radial
styloid and beyond if necessary. This approach can be extended in both directions if needed. The surgeon
should account for the location of the radial artery and seek to protect branches of the lateral antebrachial
cutaneous nerve and the superficial sensory radial nerve. Accounting for the median nerve is important during
volar flap dissection and donor muscle harvesting. Fullthickness dissection of the dorsal flap provides access to
the recipients: EPL, EDC, and ECRB. Full-thickness dissection of the volar flap provides access to the donor
muscles: PT, PL, and FCR (Fig. 17-17C). Whether one starts by preparing the donors or recipients first is
surgeon preference.
The FCR and PL are readily accessible beneath the full-thickness volar forearm flap within the superficial volar
compartments. These tendons are mobilized and harvested as distally as possible to preserve all possible
length. Proximal mobilization of the muscle bellies should allow for “straight line of pull” to the dorsal
compartment. Direct lateral (radial) dissection allows exposure of the PT tendon—located beneath the BR
musculotendinous junction deep to the emerging radial sensory nerve (96). Access is equally straightforward
between the FCR and BR protecting the radial artery or dorsal to the BR protecting the superficial radial sensory
nerve. The PT tendon is harvested with a strip of periosteum to augment its coaptation into the ECRB tendon
and mobilized proximally off the radius incorporating both its superficial and deep bellies. These 3 donors are
now ready for mobilization dorsally across the radial side of the forearm. The PL and FCR will remain superficial
to the radial artery and mobile wad tendons, but deep to sensory nerves, while the PT will remain deep to the BR
as it is weaved into the nearby ECRB superficial to the ECRL. Mobilizing the FCR
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dorsally and radially around the forearm will create a pronation moment, but whether it will or needs to offset any
lost pronation from the PT transfer is unclear. Any lost active pronation has not been shown to create real
functional issues in individuals with isolated radial nerve palsy, but nonetheless should be considered in
preoperative planning in individuals who may present with confounding injuries/conditions. In other particular
situations where the surgeon needs or prefers to both minimize lost force of contraction of the donor (concern
over FCR strength) or create a direct line of pull in order to avoid too much of a pronation force to the transfer, a
large window through the interosseous membrane will allow for a direct volar to dorsal transfer of the FCR
toward the EDC, a technique shown to be effective when using the FDS as the donor motor (97).
FIGURE 17-17 These photographs illustrate the fundamentals of the FCRmediated transfer for radial nerve
palsy. A: The radial-sided approach options are demonstrated. A “lazy-S” approach potentially increases the
area of exposure, especially for the recipient sites dorsally. A straight midaxial approach is an alternative. B: This
is the surgical approach for a patient who underwent FCR-based transfers. Note the small transverse approach
at the volar wrist, which facilitated detachment of the palmaris longus tendon. C: All three donor motors, the PT,
FCR, and PL, can all be harvested and mobilized.
Elevation of the dorsal full-thickness flap exposes the ECRB, EPL, and EDC and the extensor retinaculum. The
authors start with the deepest transfers moving superficially with each subsequent coaptation. The ECRB is
identified just dorsoulnar to the ECRL and is differentiated by the length of its tendon. The PT is woven into the
ECRB using a Pulvertaft-type weave with tension set at neutral, but no more than 10 degrees of wrist extension,
at the estimated resting length of PT set by letting the PT relax into its natural resting position once the weave is
completed. The weave is then secured with nonabsorbable suture. Next, the EDC tendons are identified proximal
to the retinaculum. Whether the surgeon chooses to include the EIP in the transfer depends upon whether the
EDC index alone will produce sufficient index MCP extension with wrist flexion tenodesis. The EDM should not
require restoration. In order to aid in setting simultaneous and parallel extension of all for fingers, the EDC is first
synchronized to each other with a set of three horizontal mattress nonabsorbable sutures while an assistant
holds all four finger MCP joints in parallel position. These sutures will be placed distal to the level of the actual
tendon transfer coaptation, but proximal enough so that they do not pass under the extensor retinaculum with
finger flexion. The authors start with the most proximal sutures and then measure the effect using intraoperative
wrist tenodesis. Adjustments to one or the other of the EDC tendons can then be made with the more distal
sutures, and the EIP can be included with subsequent synchronization sutures to make up for an index MCP
extension lag if needed. Once the synchronization is complete, the FCR is mobilized and weaved proximal to the
synchronization. Tension is set with the wrist in neutral, but no more than about 10 degrees of wrist flexion, and
wrist tenodesis should confirm relaxation of any passive tension by 20 to 30 degrees of wrist extension and
passive extension of the MCP joints by about 20 to 30 degrees of wrist flexion. Alternatively, and based upon the
individual's particular presentation, the FCR can be directed through the interosseous membrane via a large
tunnel into the EDC synchronization. Finally, the EPL is cut at the level of its myotendinous junction and
mobilized out of the 3rd extensor
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compartment toward the direction of the dorsally mobilized PL. This is done to create a combined thumb
extension-abduction moment to help create more functional thumb extension by eliminating the adduction
moment of the EPL, although this can be maintained at the surgeon's discretion. As with EDC restoration, the
thumb should relax by 20 to 30 degrees of wrist extension and extend by 20 to 30 degrees of wrist flexion. If the
PL is absent, then the EPL can be incorporated into the EDC synchronization and activated with the FCR
(91,92).
Pearls and Pitfalls

When performing EDC synchronization, start the process proximally to allow easier tension adjustments
distally.
When performing EDC synchronization, ensure the sutures do not pass into the extensor retinaculum, and
consider “venting” proximally if there is no alternative in order to avoid creating adhesions to excursion
beneath the retinaculum.
Moving the EPL out of its retinacular compartment helps eliminate the natural adduction moment created from
the sharp angle the EPL takes to the thumb after it exits the third compartment. The surgeon will often find it
helpful to reduce this moment to create more functional extension.
Always take care to protect and account for the superficial sensory nerve and the branches of the lateral
antebrachial cutaneous nerve in order to avoid creating compression neuropathies and postoperative
paresthesias and dysesthesias.
Once skin flaps are closed, the extremity is splinted with the wrist in 30 degrees of extension, the MCP joints in
full extension, and the thumb abducted with the IP joint in extension.
Complications
Extensor lag can result from improper tensioning of donor tendons to the digits. Joint contractures and
stiffness can result from prolonged immobilization and effectively negate the completed reconstruction.
Specific complications can arise with particular transfers:
Loss of wrist range of motion is seen in PT to ECRB transfers. Pronation strength deficits can result with
use of this motor donor (86).
Donation of FDS for digit extension can produce bowstringing at the donor digits. Use of FDS can also
produce flexion contracture or hypermobility of the PIP and lead to finger deformity (51,97).
Results
Procedures to restore wrist and digit extension are met with favorable results, even in the setting of chronic
radial nerve palsy (98).
Transfer of the PT to ECRB provides adequate radially biased wrist extension (97).
PT to ECRB and either FCR or FCU to restore digit extension results in favorable long-term wrist and
digit extension (92).
Comparison of the FCU, FCR, and FDS as motor donors fails to differentiate successful outcome based
on tendon transfer donor (99).
However, use of the PT motor can result in significant loss of wrist function with significant pronation
strength deficit. Functional deficit would be most detrimental to laborers if early transfers are planned as
internal splints with expected return of radial nerve function (86).
REFERENCES
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Chapter 18
Decision Making and Surgical Techniques for Treating Intercalary
Nerve Deficits: Autograft, Allograft, and Conduits
Mark C. Shreve
Peter J. Evans
INTRODUCTION
Intercalary nerve deficits can commonly result from upper extremity trauma or resection of neuromas in continuity
or tumors. If left untreated, these nerve deficits can leave a sensory or motor deficit in the patient leading to long-
term disability, loss of productivity, pain, and impaired quality of life
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(1,2). Mechanisms of injury vary from crushing, stretching, laceration or transection, ischemia, and/or metabolic
causes. Nerve injuries continue to be a challenging and complex clinic problem, and selecting the proper
treatment is difficult given the variable presentation of injury pattern and length of deficit. The literature is quite
varied in regard to indications and choices for nerve repair, ranging from direct tension-free repair to autograft,
allograft, or conduit repairs.
In treating peripheral nerve injuries, the goal is to provide a tension-free direct repair. However, this exact clinical
situation is relatively rare and also depends on whether the repair to the nerve is acute or chronic (3). Once a
nerve is injured, the ends will retract to some degree and thus require a certain amount of stretch or elongation
to directly repair the ends. This degree of elongation leads to a variable amount of decreased blood flow at the
repaired ends, with some studies showing at least a 50% decrease in blood flow with nerve elongation over 10%
and even mechanical suture pullout at more than 15% elongation (3,4). Millesi and others have shown clearly
that when a direct tensionless repair is not attainable, better results can be obtained with nerve grafting under no
tension (5,6,7,8).
Nerve injuries were originally classified by Seddon (9,10) into neuropraxia, axonotmesis, and neurotmesis.
Sunderland (11) further modified Seddon's classification to include five degrees of nerve injury that helped
predict outcomes after nerve injury, ranging from first-degree injury with no axonal loss equivalent to neuropraxia
to fifth-degree injury with axonal discontinuity and disruption of the endo-, peri- and epineurium equivalent to
neurotmesis. Later et al. (12), described a sixth-degree injury, in which the peripheral nerve at any given point
along the injury zone contains varying degrees of nerve injury between the separate fascicles with some
demonstrating minimal second- and third-degree injuries while others demonstrate more severe fourth- and fifth-
degree injuries. This leads to a varied topography of nerve injury that must be recognized and resected to obtain
a healthy level of nerve fascicle available for repair. Suturing of scarred nerve ends provides limited value as
scar inhibits revascularization, axonal regeneration, and Schwann cell migration. Resection of nerve ends until
discrete pouting fascicular bundles become evident is critical in preparing for reconstruction (13).
When a tensionless repair is not able to be achieved, then the gold standard for segmental defects has
traditionally been autologous nerve grafting (2). Autografts are low cost and have a proven track record, and
there is no risk of disease transmission. However, donor site morbidity with numbness, neuroma formation, and
scarring; increased operative time for harvest; as well as having a limited supply of available nerve donor tissue
has prompted many to seek alternatives to autografts. Importantly, clinical outcomes of nerve grafting
demonstrate an S3/M3 or better recovery in only 40% to 60% of patients, indicating that there is significant room
for improvement in current techniques of neurorrhaphy and nerve grafting.
A successful series of autogenous vein nerve conduits(14) and biodegradable polyglycolic acid tubes (15) used
to bridge sensory defects of less than 3 cm encouraged usage of conduits in peripheral nerve repair in the mid
1990s. Surgeons began using nerve conduits of up to 3 cm, based mainly on the work by Strauch and
colleagues (16) who demonstrated in a rabbit peroneal nerve excellent growth and regeneration in autogenous
vein conduits in defects less, but not greater, than 3 cm. Then, Weber et al. (17) found 0% failure in clinical gaps
less than 5 mm and 34% failure in gaps greater than 5 mm, but recommended conduits for larger gaps not
supported by data presented. Mackinnon and Dellon (15) found poor resolution in pain in gaps of 5 to 30 mm in
length, and Wangensteen and Kalliainen (18) found 31% of their patients requiring revision in gaps 2.5 to 20 mm
in length. Therefore, given these clinical results, we limit conduit repairs to gaps less than 5 mm in length.
Nerve allografts were first used in the late 1800s, but with time it was found that failures were due to
immunogenicity that necessitated immunosuppression (19,20). However, more recently there is renewed interest
in nerve allografts with the advent of processed nerve allografts, which create nonimmunogenic, acellular
allografts, devoid of inhibitor chondroitin sulfate proteoglycans, and contain beneficial characteristics of nerve
autograft (physical macrostructures, three-dimensional microstructural scaffold, and original laminin-coated
endoneurial tubes) (21). Processed nerve allograft has inherent limitations as they are absent of endogenous
Schwann cells and viable microvasculature and therefore available in a maximum diameter of 4 to 5 mm and 7
cm in length.
In determining whether to perform a direct repair, or utilize other techniques, we use the following algorithm (Fig.
18-1). First, if the proximal nerve stump is not available then a nerve transfer should be considered. If the
proximal stump is intact, next determine if the distal nerve stump is available and if not, consider muscular
neurotization. If the distal stump is available, then it should be determined if the end target (i.e., muscle or skin) is
normal and healthy. If not, then a procedure such as a tendon transfer might be better utilized.
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FIGURE 18-1 Algorithm for treatment of nerve injury.
Next it should be determined if the nerve ends, after adequate stump preparation, can be approximated without
undue tension, transposition, or bone shortening, under the full range of joint motion. A commonly used
technique to determine if there is “too much” tension is to place a single 8-0 nylon suture in the two nerve ends,
and if this is able to hold the two together, then tension is not excessive and a primary direct repair can be
performed, or we prefer a conduit-assisted repair (CAR). If unable to be repaired without tension, the subsequent
gap should be repaired with an autograft, allograft, or conduit, depending on the gap length.
Despite best intentions, variability exists in the injured wound environment, healing response, and surgeon
microsurgical skill, and we believe that by use of a CAR, nerve repair is easier and may result in improved nerve
regeneration. CARs use fewer sutures, decrease tension, avoid crumpling with misalignment of fascicles, may
limit axon escape and the amount of scar invasion, and improve nerve gliding. Conduits available commercially
are made of collagen, polyglycolic acid, polycaprolactone, and porcine submucosa, and have varying degrees of
permeability and have varying degrees of rigidity. This rigidity prevents collapsing and kinking, which is a
problem with autogenous vein conduits. However, problems have been reported with conduits made with
polyglycolic acid and polycaprolactone (22). Limitations of polyglycolic acid conduits are their high rate of
degradation, acidic degradation products, and low solubility. Limitations of polycaprolactone conduits include its
high rigidity necessitating immersion in saline prior to use, reports of needle breakage with application
necessitating larger caliber suture usage, and severe foreign body reactions and early collapse (22).
Treatment of the nerve gap can be outlined in Figure 18-2. For nerve gaps of 0 to 5 mm, we prefer to utilize a
synthetic conduit or allograft for bridging the defect in digital nerves and use nerve allograft for mixed nerves,
utilizing a 5- to 10-mm graft to minimize tension. For gaps from 5 mm to 4 cm, we utilize allograft, but autograft is
also a standard alternative with consideration for operative time and morbidity. For defects greater than 4 cm,
autograft is preferred at this time, despite the availability of allograft up to 7 cm.
FIGURE 18-2 Algorithm for treatment of intercalary nerve defects.
The preoperative preparation will vary widely with the type of injury or indication for surgery, age and health
status of the patient, size of nerve defect, and the size of nerve being repaired. Any concomitant injuries should
be fully investigated and repairs planned. Any bone, tendon, or vascular injuries should be concomitantly
addressed. Nerve injuries can be due to direct penetrating trauma from objects such as a knife or piece of
broken glass or metal, and these injuries correlate highly with a nerve transection if a sensory or motor loss is
detected. Nerve injuries can also be due to gunshot wounds or open or closed fractures, and the continuity of
the nerve in question may or may not
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be transected. This situation is less clear as to early or late exploration and repair. Often the zone of injury to the
nerve is underappreciated and evolves over time. In the situation of early exploration of a blast injury for fixation
of fractures or vascular repair, it is helpful to provisionally suture the ends of severed nerve together or at least
mark the nerve ends with suture to ease later identification and reconstruction. Each injury is unique and
requires a differing treatment strategy.
Preoperative sensibility, motor function, subjective pain, dysesthesias, and sudomotor function should be
evaluated and recorded. Sensibility can be adequately recorded with both static and moving two-point
discrimination testing. Motor strength of involved muscle should be recorded. Depending on the acuity of the
injury, electrodiagnostic testing can be helpful in recording nerve recovery and regeneration and can be helpful
in distinguishing between a neuropraxic or axonotmetic and neurotmetic injuries. These studies are only helpful
after at least 3 weeks to allow for wallerian degeneration to occur, in which neuropraxic injuries will show a
conduction block only, unlike more severe injuries.
If considering a nerve autograft, it is important to discuss with the patients that they may have a complicating
neuroma, and they will all expect a sensory loss in the dermatomal distribution supplied by the nerve being used.
For elective cases, it is helpful to perform a preoperative nerve block of the donor nerve to demonstrate this
expected area of anesthesia after harvest.
When performing a nerve repair or reconstruction, it is extremely important to ensure that the proper equipment
is available. A pneumatic tourniquet is helpful for a bloodless field. An operating microscope has been shown to
be superior to loupe magnification for microsurgical nerve repairs or reconstructions (23). A supply of 8-0, 9-0,
and 10-0 monofilament sutures with a large radius of curvature is preferred for neurorrhaphy (versus vascular
repair) and a taper or reverse cutting (but not spatula) point is optimal. Depending on the situation, intraoperative
nerve stimulators are helpful, and ensure an adequate supply and size of nerve conduits and/or allograft nerve.
TECHNIQUE
Peripheral nerve repairs or reconstructions can be performed with the patient under general, regional, or even
local anesthesia. However, if regional or local anesthesia is used, it is important that the patient be cooperative
as intraoperative motion is to be avoided. Typically, general anesthesia is preferred given the prolonged
operative time required for nerve reconstructions or repairs.
Conduit-Assisted Repair
1. An appropriately selected surgical approach is used to obtain access to the injured nerve. Prior lacerations
should be incorporated in the incision if they provide adequate access to the nerve injury site. For digital nerve
repair, Brunner zigzag incision is commonly used in the finger and hand. Thick skin flaps should be raised
where necessary.
2. As with all nerve repairs, the initial injury or insult to the tissues will determine the quality and area of nerve
injury. Lacerations should be explored and depending on the location any concomitant tendon or vascular
injuries should be identified and addressed. These repairs are beyond the scope of this chapter. But in
general any flexor or extensor tendon or digital arterial repairs should be performed prior to the repair of the
nerve.
3. It cannot be underestimated how critical it is to perform an adequate debridement of the nerve ends in order to
expose healthy, pouting axons and freely bleeding epineurial and endoneurial vessels. This should be initiated
under loupe magnification and completed under the microscope. It is our contention that it is rare that even a
sharp injury provides a tensionless repair, especially when explored several days post injury, and after
adequate debridement a gap is always present. Neurolysis should include mobilizing the proximal and distal
segments to lessen the gap distance and tension on the repair.
4. As with all nerve repairs, proper alignment of the fascicles is necessary. Several techniques can be used to
help assure that the fascicles are best directed to the right location from proximal to distal. Direct visualization
of the nerve fascicular patterns and topography can be used to properly align the nerve ends. Surface vessels
can also be used on larger more proximal nerves. We have found more complex techniques such as nerve
stimulation and intraoperative histologic staining, although useful and proven valuable, to be too cumbersome
intraoperatively for routine nerve repairs.
5. Throughout preparing the nerve ends for repair, it is important to handle the nerve as delicately as possible.
Grasp the nerve by the epineurium with the forceps and avoid having to use multiple grasps. It is best to
sharply incise any nonviable nerve ends with a scalpel perpendicular to the fascicles, which can be done
conveniently with a nerve sizer/cutter available from several vendors (Fig. 18-3). Keep the nerve ends
continuously moist with saline-moistened gauze when not in use.
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6. When performing a CAR, the conduits can be used in two ways: as a wrap or conduit with a slit along the
longitudinal aspect or as with a size-matched intact conduit (our preferred method). Prior to performing a
repair, it is important to determine which type of conduit that will be used. If a size-matched conduit is to be
used then this must first be placed over the nerve and slid either proximal or distal prior to the repair, as seen
in Figure 18-4. With the longitudinally slit size-matched conduit or wrap technique, the product is set aside
until after placing two reapproximating epineurial sutures (see 9).
7. Under the operating microscope, two reapproximating sutures with 8-0 or 9-0 nylon suture are placed in the
epineurium at 180 degrees from each other, as seen in Figure 18-5. It is critically important to not over tighten
these two sutures as this would cause the fascicles to bunch up at
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the repair site and misalign endoneurial tubes; only the axoplasm should abut and the epineurium should be
within 0.5 mm. This is not a vascular repair, and overtightening of sutures will downgrade the repair and basic
science evidence indicates that a gap is required for neurotropism to work (19), although we advocate only the
slightest gap if any.
8. When using an intact size-matched conduit, prior to suturing the nerve ends, the appropriately sized conduit is
slid up the proximal or down the distal nerve stump, the nerve is repaired as discussed before with two nylon
sutures 180 degrees from each other, and then the conduit is slid back to cover the repair site, as seen in
Figure 18-6. The conduit is then sutured both proximally and distally with a simple nylon epineurial suture, 90
degrees orthogonal to the plane of the first two sutures. This technique requires less time than a traditional
neurorrhaphy and the wrap technique (see 9), reduces the suture burden at the repair site, but takes some
forethought in selecting a size-matched conduit prior to initial nerve suturing.
9. If a wrap or a longitudinally slit conduit is used, then it should be size matched. The conduit/wrap is then
placed around the nerve repair site gently and another 8-0 or 9-0 nylon suture is placed through the end of the
conduit and through the epineurium in simple fashion both at the proximal and distal ends, as seen in Figure
18-7, away from the actual neurorrhaphy site. This serves to hold the nerve conduit/wrap in the appropriate
location covering the nerve repair site and adds strength to the construct. The slit along the length of the
nerve conduit is then closed with either interrupted or running nylon suture or the wrap is closed similarly with
microsurgical ligature clips. It is important to ensure there is no kinking or bending of the nerve conduit when it
is applied to the nerve repair site.
10. Adjuncts such as fibrin glue can be applied to the repair construct if desired (24). Fibrin glue acts as an
adhesive cylinder and barrier around the repair site construct and may possibly help as a barrier to prevent
scar tissue formation in the repair site, but it does not remain in the wound beyond a couple of weeks.
Compared to sutures it has an inferior holding strength, but was found to prevent gapping at the repair site
(24). We do not routinely use fibrin glue, and never use it as a replacement for suture fixation of the nerve
ends in highly mobile extremities. It has a place in low excursion supraclavicular plexus wounds.
11. We do not recommend using a conduit alone, without first placing two epineurial sutures as in 7 above as
correct nerve reapproximation and rotation cannot be achieved adequately.
12. After repair meticulous, hemostasis should be obtained using bipolar cautery prior to a standard closure;
cautery should not be used on the nerve directly.
FIGURE 18-3 Nerve sizer/cutter.
FIGURE 18-4 Size-matched nerve conduit being slid over proximal stump prior to repair.
FIGURE 18-5 CAR with two reapproximating sutures being placed and lightly tied 180 degrees from each other.
FIGURE 18-6 CAR using intact size-matched conduit with the conduit being slid over repair site and sutured at
each end.
FIGURE 18-7 CAR using a wrap conduit. Note longitudinal suture to close the slit.
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Conduit Repair for a Gap
1. After exposure and debridement of the injured nerve ends, if a gap exists up to 5 mm a conduit is used for
repair of common digital nerves where joint bending will not interfere with its stability. Once the nerve ends are
ready for repair, an appropriately sized commercially available nerve conduit is selected. We do not utilize
autogenous vein conduits. Use of a synthetic conduit provides a protective environment for the sprouting
axons of the proximal stump, and helps to contain the fibrin cable that forms between the two stumps.
2. Repair of the nerve proceeds in a similar fashion to the CAR, but with some important differences. The two
nerve stumps are adequately aligned with each other in the appropriate rotation/orientation. The conduit is
then slid onto the proximal stump and sutured with 8-0 or 9-0 nylon suture in simple fashion using two sutures
180 degrees from each other (Fig. 18-8). Only place the suture through the epineurium on the nerve and do
not unduly tension the knot. Slide the distal nerve stump into the conduit. A simple repair proceeds by placing
two sutures through the conduit into the epineurium of the proximal stump 180 degrees from each other.
3. A second/alternative technique is to use an entubulation horizontal mattress suture; first pass from outside-in
the conduit, horizontal mattress across epineurium of the proximal stump about 3 mm from nerve end, then
back inside-out conduit completing the horizontal mattress and pulling the nerve into the conduit. This is
followed up by a simple suture 180 degrees from that proximally and a pair of simple sutures at the distal end
(17).
4. This completes the conduit repair. Fibrin glue may or may not also be used as an adjunct. Ensure there is no
kinking of the nerve conduit tube. The conduit should be gently filled/flushed with saline after repair is
complete (17).
5. The wound is then closed in the surgeons preferred manner.
FIGURE 18-8 Conduit repair with short gap (less than 5 mm).
Allograft Repair
We do not feel the literature supports the use of conduits for gaps greater than 5 mm, and the claim by Weber et
al. (17) in their conclusions that conduits could be used for gaps up to 3 cm was not substantiated by the data
within the manuscript. We therefore use allograft (typically) or autograft nerve for all repairs that are over 5 mm in
length. Allografts are a good option as there is an unlimited supply, decreased operative time by eliminating need
for harvesting, and no donor site morbidity. Data is promising for the use of allograft nerve, especially up to nerve
gaps of 3 cm (25), although it has been shown to be equivalent to autograft nerve in gaps of up to 5 cm (1). One
might consider that the slight inferiority of allograft, compared to autograft, is offset by these factors and is
minimal compared to the challenge that nerve repair still faces even under ideal conditions with autogenous
nerve (about 50% S3/M3 return in function).
As seen in Figure 18-2, we utilize processed nerve allograft in nerve gaps of 5 mm to 4 cm, but in gaps over 4 cm
we still favor autograft over allograft in most situations.
1. The exposure and preparation of nerve ends is the same as for repairs using conduit-assisted technique or
conduit technique as described above.
2. The gap is visualized under the surgical microscope and the gap length is measured, as well as the required
diameter/size of the host distal and proximal nerve ends.
3. Processed nerve allograft is available in varying sizes from 15 mm to 70 mm in length by 1 to 2 mm up to 4 to 5
mm in diameter. Depending on the size of the gap, the appropriate graft is chosen and divided into lengths
required.
4. The nerve allograft is then sharply cut to fit the desired gap length using a fresh scalpel blade with a nerve
sizer/cutter. Cut grafts are 10% to 15% longer than the gap length in order to ensure that there is no tension at
the nerve repair sites when completed.
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5. The nerve graft is then placed within the tissue bed between the proximal and distal nerve stumps. The
proximal end is typically sutured first. Using an 8-0 nylon suture, a simple suture is placed through epineurium
of the proximal stump and nerve graft. Then 180 degrees to that suture another simple suture is placed.
6. If using size-matched conduits, these can be slid up along the allograft, the first over the proximal repair site
and the second left toward the distal end. The conduit is secured proximally as above in CAR, section 8.
7. The same is performed at the distal end of the allograft to affix it distally. This provides a 4 suture repair.
8. The second conduit is slid over the distal repair site and secured as in CAR, Figures 18-4, 18-5 and 18-6.
9. If using a nerve wrap long enough to span both repair sites instead of a size-matched conduit, it can be
secured with two simple sutures of 8-0 nylon at either end or ligaclips. Alternatively, two wraps can be used to
cover only each anastomosis site separately; both are seen in Figure 18-9.
10. If the diameter of the nerve being repaired is larger than the graft size, then multiple nerve allograft cables can
be used in order to repair each fascicle in a similar manner as described above. The conduit is used to
enclose all cables and host nerve as above.
11. In some situations, as in Mackinnon's sixth-degree injury, a whole nerve throughout its cross section might not
be injured or only a partial nerve laceration might be present. In these situations, resection of nonviable nerve
tissue may represent only a percentage of the cross-sectional area, and potentially only one fascicle may
need grafting. In this situation, the fascicles are prepared in a similar manner and the graft interposed and
sutured as described above. A nerve conduit or wrap can then be placed and affixed around the entirety of the
injured nerve as previously described and seen in Figure 18-9.
FIGURE 18-9 Allograft repair with (A) one conduit to span both repair sites or (B) two separate conduits at each
repair site.
Autograft Repair
As discussed previously, in gap defects of longer lengths (greater than 4 cm) and in larger mixed and motor
nerves, we prefer to use an autografting technique. Autografts that can be routinely employed are the sural
nerve, medial antebrachial cutaneous nerve (MABCN), and the distal sensory portion of the posterior
interosseous nerve (PIN) at the wrist.
1. The injured nerve ends are prepared in the same manner as previously described, and the gap length and
nerve diameter requirements are assessed.
2. There are multiple options for nerve autograft and each is selected based on the requirements needed with
single short grafts needing only the distal sensory portion of the PIN, single longer grafts the MABCN, and
multiple short or long grafts needing the MABCN or sural nerve, respectively.
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a. The sural nerve is purely sensory and descends along the lateral border of the Achilles tendon in the leg
with the small saphenous vein innervating the lateral aspect of the ankle and foot. It is harvested by making
a short longitudinal incision between the lateral malleolus and the calcaneus, identifying the nerve distally,
and tracing more proximally either with a longitudinal incision, multiple short transverse incisions, or a
tendon stripper. This is performed under tourniquet control on the thigh. A graft of up to 40 cm can be
obtained with 6 to 8 fascicles, although in some patients this nerve is smaller than expected.
b. The MABCN is purely sensory with the anterior branch innervating the medial surface of the forearm and
the posterior branch innervating the posterior aspect of the elbow and forearm. Typically, we harvest the
anterior branch to avoid loss of sensation of the olecranon. The nerve passes between the medial
epicondyle and biceps tendon at the elbow and typically lies on the flexor carpi ulnaris muscle. It is
harvested by making a longitudinal incision in the proximal anteromedial forearm, starting 2 cm distal and 2
cm anterior to the medial epicondyle and is found within the subcutaneous tissue. The incision is extended
distally depending on the length required. A graft of 20 cm in length can be obtained with 3 to 4 fascicles.
c. The PIN, more specifically its distal portion, is purely sensory and runs in the floor of the fourth dorsal wrist
compartment under the finger extensor tendons with the posterior interosseous artery, providing
proprioceptive sensation to the wrist capsule. It can be harvested by making a longitudinal incision just ulnar
to Lister's tubercle and extending proximally, the tendons of the fourth dorsal compartment are retracted
ulnarly and the PIN is found on the radial aspect of the floor of the fourth compartment. It can be tracked
proximally 4 to 5 cm, and this length of graft is usually obtained with 1 to 2 fascicles. This nerve is
commonly resected during many procedures using an approach to the dorsal wrist to denervate the wrist
capsule postoperatively.
d. Given the peripheral nerves inherent arborization, the directionality of the nerve autograft should be
reversed to reduce the risk of axonal escape from any small branches along the length of the nerve.
3. Once the nerve autograft is harvested, a CAR is performed as previously described for nerve allografts. The
repair may require only a single cable in smaller diameter nerves, or grafting multiple cables for larger
diameter nerves.
Pearls and Pitfalls

Repair of poor quality proximal and distal nerve stumps assures a downgrade of recovery following repair. It is
critical to debride and resect any damaged fascicle ends back to healthy, pouting axons and brisk blood
supply, typically creating a gap and precluding direct neurorrhaphy. Different degrees of nerve injury can be
present at the same point in an injured nerve and the extent of axonal injury might not be present immediately
after the injury.
A nerve should not be repaired in tension. Take any nearby joints through a full range of maximal motion to
assess tension at the repair site. Typically, if a single 9-0 nylon suture is unable to hold the nerve ends,
together excessive tension is present (26). It is important to recognize that the situation of a direct tension-free
repair is relatively rare and employ other techniques of repair when necessary.
Nerve tissue should be handled with care using fine-tipped micro-instruments. Take care not to crush nerve
tissue between the forceps.
When performing a CAR remember to “preload” the nerve stump with the conduit prior to initially suturing the
nerve ends together to facilitate efficiency of repair. Ensure the selected conduit is slightly larger than the
largest nerve stump that will be coapted.
When using a nerve graft, measure the graft to be 10% to 15% longer than the needed length so as to reduce
the amount of tension present at the coaptation sites.
Meticulous hemostasis should be obtained to avoid postoperative hematoma formation.
The management of the repair postoperatively will depend on the situation of the nerve repair. The repair site
should be immobilized for a short period of time, typically 7 to 10 days, by immobilizing any nearby joints.
However, if there is concern for undue tension on the nerve repair site, then this length of immobilization could
be extended. At least for the first 6 weeks after repair any extremes of range of motion should be avoided, and
the use of removable splints can be added, such as extension block splints, etc. The patient should be referred
to occupational therapy for specific rehabilitation depending on the nerve repaired and its sensory or motor
distribution, which is beyond the scope of this chapter.
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Complications
Proper administration of perioperative antibiotics is important and attempts to shorten operative time should
be employed to minimize infection risk. Postoperative hematoma can occur, and should be prevented by
obtaining meticulous hemostasis during and after the repair with the tourniquet down. Synthetic conduits
have been noted to be safe and with minimal complications related to their use (21). Similarly, processed
nerve allograft use has also been reported to be safe with studies showing no implant-related
complications, tissue rejections, or adverse reactions (1). As noted previously, donor site morbidity
associated with nerve autografting may include infection, functional compromise, postoperative
paresthesias, and postoperative neuroma formation.
RESULTS
Overall the results of nerve regeneration after repair have not been optimal, and the quality of recovery after
repair depends on the amount of axons ultimately reaching their end organ targets (13). This quality of
recovery depends on many factors including the patient's age, level of nerve injury, type and cause of nerve
injury, and timing of the repair. Meaningful recovery has been described historically using the Medical
Research Council Classification (MRCC) developed by Seddon (10). Motor recovery is measured from M0
with no contraction to M5 as complete recovery, with a good or functional result being defined as M3 or
better (action against gravity only) (27). Sensory function is measured from S0 as absence of sensibility to
S4 as complete recovery, with a good result as S3 or better (pain and touch perception with two-point
discrimination greater than 15 mm) (27).
Recently, He et al. (28) performed a systematic review of the factors predicting recovery of sensory and
motor function after peripheral nerve repair. They included 71 articles in their review finding that time to
repair, repair materials (i.e., using a nerve allograft or conduits), and the nerve injured were independent
predictors of motor outcome after repair. The nerve injured was the main factor affecting rate of good to
excellent motor recovery. Multivariate analysis for sensory recovery showed that a shorter defect length
was an independent predictor of good to excellent recovery.
Weber et al. (17) in 2000 prospectively randomized patients to digital nerve repair with nerve conduits or
repair with direct repair or autografts with good results for repairs using synthetic conduits. Outcomes were
measured by sensory two-point discrimination. They found overall no significant difference between the
conduit repair group (gap length 7 ± 5.6 mm) or the standard repair (direct neurorrhaphy or autograft) group
(gap length 4.3 ± 6.7 mm). However, when breaking it down to repairs less than 4 mm in length, the conduit
group actually faired better than the direct repair group in regards to average moving two-point
discrimination (3.7 vs. 6.1). Interestingly, in gaps 5 to 7 mm, they found no difference between the two
groups and, in gaps greater than 8 mm, they found better results in those repaired with conduits compared
to autografting. Despite showing only good results in short nerve gaps, Weber et al. (17) without support
concluded that conduits were superior to nerve graft in gaps up to 3 cm. However, multiple further studies
have shown good results in only limited applications with short nerve gaps around 1 cm (29,30,31).
Reviews of the results of processed nerve allograft have demonstrated that they are safe and effective at
repairing peripheral nerve defects (1,21,25). Cho et al. (1), looking specifically at an upper extremity subset
population of the RANGER Study registry, concluded that processed nerve allografts were both safe and
effective for peripheral nerve gaps of 5 to 50 mm in length and that their outcomes compared favorably with
those for nerve autograft, and exceeded the results for conduit repairs. They defined meaningful recovery
as those with recovery to at least an S3 or M3 on the MRCC scale. They found no implant-related
complications and noted an improvement in sensory or motor function in 89% of the repairs with a mean
gap length of 23 ± 11 mm (range 5 to 50 mm). Overall 86% achieved a meaningful recovery of S3 or M3 or
better, with 89% meaningful recovery for digital nerves. When stratified by gap length (less than 15 mm, 15
to 29 mm, and 30 to 50 mm), meaningful recovery was found in 100%, 82%, and 90%, respectively.
Ducic et al. (32) reviewed their outcomes of peripheral nerve repair using a treatment algorithm based on
the gap length. Nerve repairs were performed by direct primary repair, nerve conduit, allograft, and
autograft repair. In their 54 nerve repairs performed at an average 22.3 weeks from injury, they found no
significant difference in outcome between each repair type when it was applied to the appropriate sized
gap, although this was based solely on QuickDASH scores and not a dedicated evaluation of sensory or
motor recovery.
After Millesi popularized the classic nerve autograft (6), outcomes have been documented over the last five
decades. Reviews of nerve autograft recovery have demonstrated a range of recovery. Frykman and
Gramyk report that sensory nerve repairs less than 50 mm in length report 90% meaningful recovery, while
gaps 50 mm and greater report 64% meaningful recovery (33). Ruijs et al. conducted a meta-analysis of
function outcomes for median and ulnar nerves, reporting sensory recovery of S3+ or more in 40% of
patients and motor recovery of M4 or more in 47% of patients (34). What is
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clear is that our past results of nerve repair have significant room for improvement and conceptually
adopting a more biological means of neurrorhaphy such as the CAR may be one step in that direction.
REFERENCES
1. Cho MS, Rinker BD, Weber RV, et al.: Functional outcome following nerve repair in the upper extremity
using processed nerve allograft. J Hand Surg Am 37(11): 2340-2349, 2012.
2. Dahlin LB: Techniques of peripheral nerve repair. Scand J Surg 97(4): 310-316, 2008.
3. Clark WL, Trumble TE, Swiontkowski MF, et al.: Nerve tension and blood flow in a rat model of immediate
and delayed repairs. J Hand Surg Am 17(4): 677-687, 1992.
4. Driscoll PJ, Glasby MA, Lawson GM: An in vivo study of peripheral nerves in continuity: biomechanical and
physiological responses to elongation. J Orthop Res 20(2): 370-375, 2002.
5. Berger A, Millesi H: Nerve grafting. Clin Orthop Relat Res 133: 49-55, 1978.
6. Millesi H, Meissl G, Berger A: The interfascicular nerve-grafting of the median and ulnar nerves. J Bone
Joint Surg Am 54(4): 727-750, 1972.
7. Rodkey WG, Cabaud HE, McCarroll HR Jr: Neurorrhaphy after loss of a nerve segment: comparison of
epineurial suture under tension versus multiple nerve grafts. J Hand Surg Am 5(4): 366-371, 1980.
8. Terzis J, Faibisoff B, Williams B: The nerve gap: suture under tension vs. graft. Plast Reconstr Surg 56(2):
166-170, 1975.
9. Seddon HJ, Medawar PB, Smith H: Rate of regeneration of peripheral nerves in man. J Physiol 102(2):
191-215, 1943.
10. Seddon HJ: A classification of nerve injuries. Br Med J 2(4260): 237-239, 1942.
11. Sunderland S: A classification of peripheral nerve injuries producing loss of function. Brain 74(4): 491-
516, 1951.
12. Mackinnon SE, Dellon AL: Surgery of the peripheral nerve. New York Stuttgart, New York: Thieme
Medical Publishers, G. Thieme Verlag, xxiv, 1988: 638.
13. Birch R: Nerve Repair. In: Wolfe SW, Pederson WC, Hotchkiss RN, Kozin SH, eds. Green's operative
hand surgery. 6th ed. New York: Churchill Livingstone, Vol 2, 2010: 1036-1074.
14. Chiu DT, Strauch B: A prospective clinical evaluation of autogenous vein grafts used as a nerve conduit
for distal sensory nerve defects of 3 cm or less. Plast Reconstr Surg 86(5): 928-934, 1990.
15. Mackinnon SE, Dellon AL: Clinical nerve reconstruction with a bioabsorbable polyglycolic acid tube. Plast
Reconstr Surg 85(3): 419-424, 1990.
16. Strauch B, Ferder M, Lovelle-Allen S, et al.: Determining the maximal length of a vein conduit used as an
interposition graft for nerve regeneration. J Reconstr Microsurg 12(8): 521-527, 1996.
17. Weber RA, Breidenbach WC, Brown RE, et al.: A randomized prospective study of polyglycolic acid
conduits for digital nerve reconstruction in humans. Plast Reconstr Surg 106(5): 1036-1045; discussion 46-8,
2000.
18. Wangensteen KJ, Kalliainen LK: Collagen tube conduits in peripheral nerve repair: a retrospective
analysis. Hand (NY) 5(3): 273-277, 2010.
19. Evans PJ, Midha R, Mackinnon SE: The peripheral nerve allograft: a comprehensive review of
regeneration and neuroimmunology. Prog Neurobiol 43(4): 187-233, 1994.
20. Evans PJ. The Peripheral Nerve Allograft: A Decade of Advancement. Atlas Hand Clin 10(1): 187-197,
2005.
21. Brooks DN, Weber RV, Chao JD, et al.: Processed nerve allografts for peripheral nerve reconstruction: a
multicenter study of utilization and outcomes in sensory, mixed, and motor nerve reconstructions.
Microsurgery 32(1): 1-14, 2012.
22. Kehoe S, Zhang XF, Boyd D: FDA approved guidance conduits and wraps for peripheral nerve injury: a
review of materials and efficacy. Injury 43(5): 553-572, 2012.
23. Bernstein DT, Hamilton KL, Foy C, et al.: Comparison of magnification in primary digital nerve repair:
literature review, survey of practice trends, and assessment of 90 cadaveric repairs. J Hand Surg Am 38(11):
2144-2150, 2013.
24. Isaacs JE, McDaniel CO, Owen JR, et al.: Comparative analysis of biomechanical performance of
available “nerve glues.” J Hand Surg Am 33(6): 893-899, 2008.
25. Karabekmez FE, Duymaz A, Moran SL: Early clinical outcomes with the use of decellularized nerve
allograft for repair of sensory defects within the hand. Hand (NY) 4(3): 245-249, 2009.
26. Sunderland IRP, Brenner MJ, Singham J, et al.: Effect of tension on nerve regeneration in rat sciatic
nerve transection model. Ann Plast Surg 53(4): 382-387, 2004.
27. Isaacs J. Treatment of acute peripheral nerve injuries: current concepts. J Hand Surg Am 35(3): 491-497;
quiz 8, 2010.
28. He B, Zhu Z, Zhu Q, et al.: Factors predicting sensory and motor recovery after the repair of upper limb
peripheral nerve injuries. Neural Regen Res 9(6): 661-672, 2014.
29. Battiston B, Geuna S, Ferrero M, et al.: Nerve repair by means of tubulization: literature review and
personal clinical experience comparing biological and synthetic conduits for sensory nerve repair.
Microsurgery 25(4): 258-267, 2005.
30. Lohmeyer JA, Siemers F, Machens HG, et al.: The clinical use of artificial nerve conduits for digital nerve
repair: a prospective cohort study and literature review. J Reconstr Microsurg 25(1): 55-61, 2009.
31. Taras JS, Jacoby SM, Lincoski CJ: Reconstruction of digital nerves with collagen conduits. J Hand Surg
Am 36(9): 1441-1446, 2011.
32. Ducic I, Fu R, Iorio ML: Innovative treatment of peripheral nerve injuries: combined reconstructive
concepts. Ann Plast Surg 68(2): 180-187, 2012.
33. Frykman G, Gramyk K: Results of nerve grafting. In: Gelberman R, ed. Operative nerve repair and
reconstruction. Philadelphia: JB Lippincott, 1991: 553-568.
34. Ruijs AC, Jaquet JB, Kalmijn S, et al.: Median and ulnar nerve injuries: a meta-analysis of predictors of
motor and sensory recovery after modern microsurgical nerve repair. Plast Reconstr Surg 116(2): 484-494.
discussion 495-486, 2005.
Chapter 19
Surgical Options for Recurrent Carpal Tunnel Syndrome
Loukia K. Papatheodorou
Dean G. Sotereanos
INTRODUCTION
Compression of the median nerve at the wrist, known as carpal tunnel syndrome, is the most common
entrapment neuropathy in the upper extremity affecting 10% or more of the general population (1). Even though
carpal tunnel surgical release is generally considered efficacious, recurrence of symptoms of carpal tunnel
syndrome can occur in up to 30% of patients postoperatively (2,3,4). The persistence of symptoms of carpal
tunnel syndrome is commonly associated with incomplete initial release of the transverse carpal ligament,
whereas recurrence of symptoms, after a distinct symptom-free period, is usually secondary to cicatrix
surrounding of the median nerve (2,5).
Treatment of recalcitrant carpal tunnel syndrome remains a challenging problem. Nonsurgical treatment
(splinting, injection, nonsteroidal anti-inflammatory drugs) may temporarily alleviate pain but usually fails to
provide a long-term relief of the symptoms. Revision surgery, repeated median nerve decompression, even with
external or internal neurolysis, does not always lead to sufficient relief of symptoms. Secondary decompression
can cause scar reformation of the median nerve with the surrounding tissue, developing further compression of
the nerve, resulting in traction or adhesive neuritis (5).
To manage this complex problem and prevent further adhesion to the median nerve, several techniques
including interposition flaps and adhesion barriers, biologic or synthetic, have been proposed to cover or wrap
the nerve. These supplementary techniques include various soft-tissue interposition flaps and nerve wrapping
(vein wrapping, nerve protectors). The optimal treatment may consist of a combination of procedures. The goal
of treatment of recurrent carpal tunnel syndrome is to create an environment for scar-free healing of the
neurolyzed nerve, preventing recurrent cicatrix, improving the gliding of the median nerve during wrist motion,
and promoting the nerve functional recovery.
TISSUE INTERPOSITION FLAPS

A variety of tissue interposition flaps (fat, muscle, or free flaps) have been used to cover and provide
neovascularization to the median nerve in revision carpal tunnel surgery. However, many of these flaps require
technically demanding dissection and sacrifice of normal tissue, and the results are not reliably superior to other
techniques.
The abductor digiti minimi muscle flap, as described initially by Milward et al. (6) and later by Reisman and
Dellon (7), necessitates an extensive dissection with a long arc of rotation and the
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sacrifice of an important hypothenar muscle. Although this flap provides a well-vascularized tissue for coverage
of the median nerve in recalcitrant carpal tunnel syndrome, residual abduction of the small finger may be noticed
postoperatively. Wilgis (8) reported the lumbrical flap as an alternative option, which relies on a small intrinsic
muscle. However, this flap does not always ensure adequate proximal coverage of the median nerve at the wrist,
and long-term outcomes have not been published.
Dellon and Mckinnon (9) described the pronator quadratus muscle flap based on the neurovascular bundle of
anterior interosseous artery and nerve. But this flap requires technically demanding dissection and cannot offer
sufficient distal coverage of the median nerve further than the proximal wrist flexion crease. Rose et al. (10)
proposed the palmaris brevis turnover flap. Nevertheless, this flap frequently leads to insufficient coverage of the
median nerve due to small size of the muscle. Additionally, the muscle is absent in at least 2% of the patients.
The reverse radial artery fascial flap according to Tham et al. (11) allows sufficient coverage of the scarred
segment of the median nerve. The flap is based on reverse flow through the ulnar artery sacrificing the radial
artery. However, the communication between the radial and ulnar artery is absent in approximately 4% of the
patients (12). An alternative fasciocutaneous island flap is the posterior interosseous artery flap, which relies on
branches of the posterior interosseous artery (13). An intact communication between the anterior and posterior
interosseous arteries is required to provide the retrograde flow to the flap. Yet, this communication is absent in
5% of the general population (14).
Free flaps of gliding tissue have also been described for coverage of the scarred median nerve such as the
omentum and the adventitial flap based on the thoracodorsal vessels (15). These flaps are far more technically
demanding with severe donor site morbidity, and, therefore, they should be used more as salvage procedures for
patients with multiple previous procedures.
HYPOTHENAR FAT PAD FLAP

In contrast to the above reported interposition flaps, the hypothenar fat pad flap is not technically difficult, locally
available, and expendable. It is a vascularized pedicle flap, which is based on the depth of the vasculature from
the ulnar artery to the hypothenar fat. The hypothenar fat pad flap was initially described by Cramer and
subsequently modified by Strickland and Mathoulin (16,17). It is the most commonly used flap for recalcitrant
carpal tunnel syndrome providing a well-vascularized interposition tissue over the median nerve and the radial
leaf of the transverse carpal ligament.
Indications
The hypothenar fat pad flap is indicated as a supplementary procedure to revision decompression of the
median nerve in:
Persistence or recurrence of symptoms of carpal tunnel syndrome
Failure of nonoperative treatment (splinting, injection)
Significant median nerve hypersensitivity at the wrist with no damage of the palmar cutaneous branch of
the median nerve
Progressive neurologic deficit in median nerve function (thenar muscle atrophy, expanded twopoint
discrimination)
Technique
The procedure is performed under regional or general anesthesia and tourniquet control. Previous incisions for
carpal tunnel release are used and extended both proximally and distally to identify the compressed median
nerve in healthy tissues (Fig. 19-1). After exposure of the nerve to unscarred environment both proximally and
distally, the dissection is continued toward the scarred section of the nerve using loupe magnification. The
median nerve is released from the surrounding scar tissues and adhesions (Fig. 19-2). Internal neurolysis under
operating microscope is performed only when there is severe compression and thinning of the nerve, lack of
epineural vascularity, and severe muscle wasting. We routinely perform epineurotomy for severe nerve
compression. Internal neurolysis is performed concomitantly if scar is noted between fascicules. Rarely is an
entire epineurectomy performed.
To harvest the hypothenar fat pad flap, the Guyon's canal can be initially released and the ulnar nerve and artery
are identified and protected throughout the dissection of the flap (Fig. 19-3). The fat flap is raised by sharp
subcutaneous dissection from the hypothenar eminence. Care is taken to maintain the vascularity of the
hypothenar skin flap to avoid skin necrosis postoperatively. The harvesting proceeds from the distal wrist crease
to midpalm, and while mobilizing the fatty tissue, care
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is taken to avoid injury of the digital nerves to the ring and small fingers, which are often buried in the fat. Deep
mobilization of the flap can be achieved by excising a segment of the ulnar leaf of the transverse carpal ligament.
FIGURE 19-1 Previous carpal tunnel release incision (black arrows) is extended proximally and distally.
FIGURE 19-2 Median nerve after exposure and neurolysis. Note lack of epineural vasculature (black arrows).
FIGURE 19-3 The hypothenar fat pad flap (HFPF) is raised by subcutaneous dissection from the hypothenar
eminence after identification and protection of the ulnar neurovascular structures (black arrow). M, median
nerve.
When an adequate fat flap has been harvested, the flap is mobilized to determine whether it can be easily
advanced over the median nerve to the radial remnant of the transverse carpal ligament (Fig. 19-4). If sufficient
mobilization is not achieved, additional dissection is carried out preserving the ulnar pedicle of the flap. Once the
harvesting is complete, the flap is hinged like a book cover over the median nerve and is sutured to the radial
remnant of the transverse carpal ligament (Fig. 19-5). Attention should be paid to suture the flap without tension
placing the sutures from the radial edge of the flap to the radial edge of the transverse carpal ligament. Gentle
compression of the radial and ulnar sides of the hand can facilitate to secure a tension-free flap. The tourniquet
is deflated, and meticulous hemostasis is performed. After routine skin closure, the wrist is immobilized in short
arm splint.
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FIGURE 19-4 The hypothenar fat pad flap (HFPF) is mobilized for coverage of the median nerve (M).
FIGURE 19-5 The hypothenar fat pad flap (HFPF) is sutured to the radial remnant of transverse carpal ligament
(black arrows) without tension covering the median nerve.
Pearls and Pitfalls

Harvesting of the flap requires knowledge of the anatomy of the neurovascular structures. The ulnar digital
nerve of the small finger and common digital nerve to the fourth web run deep to the distal third of the fat pad
after branching from the ulnar nerve in Guyon's canal.
Guyon's canal should be released for better visualization and protection of the ulnar nerve and artery
throughout the harvesting of the flap.
Dissection should be carried out without devascularization of the hypothenar skin to avoid skin necrosis
postoperatively.
A segment of the ulnar leaf of the transverse carpal ligament is excised to facilitate the mobilization of the flap.
The flap should be raised until its radial margin easily reaches the radial wall of the carpal canal.
A short arm splint with wrist in slight extension is applied for 2 weeks postoperatively. At that time, sutures are
removed and active and passive exercises are started. Scar massage and desensitization can also be initiated. A
strengthening program is recommended, if required. Heavy lifting is to be avoided for 6 weeks postoperatively.
Complications
A very low complication rate has been reported including ulnar digital nerve paresthesias in the small finger
and numbness over the hypothenar eminence, which is usually transient (16,17,18,19,20). However, a
permanent nerve injury remains a potential complication.
Skin necrosis may result, if the vascularity of the hypothenar skin is not preserved during the dissection of
the flap. Superficial infection of the scar is another complication, which usually resolves with local wound
therapy and oral antibiotics.
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RESULTS
Several clinical studies have demonstrated reliable clinical results with the use of hypothenar fat pad flap in
patients with recalcitrant carpal tunnel syndrome. Good to excellent results have been reported in up to
95% (16,17,18,19,20,21). Improvement of the pain and sensation have been noticed in the majority of
patients with recurrent carpal tunnel syndrome after revision median nerve decompression and hypothenar
fat pad flap (16,17,18,19,20,21).
The hypothenar fat pad flap provides interposition tissue of sufficient size to cover the median nerve in the
carpal tunnel preventing the scar reformation. Furthermore, it provides neovascularization to the median
nerve improving to aid nerve regeneration. However, full recovery of both sensory and motor nerve deficits
may not be achieved regardless of the use of the flap or not.
NERVE WRAPPING
Several materials, such as allograft or autograft vein grafts, and synthetic devices have been used as adhesion
barriers for recalcitrant carpal tunnel syndrome. The ideal nerve wrapping material should prevent adhesions
and inhibit scar reformation around the previously scarred segment of the nerve, protecting the nerve from
further compression and improving nerve gliding during arm motion.
AUTOLOGOUS VEIN NERVE WRAPPING

The use of vein wrapping was initially studied in a rat model, showing that the autologous vein graft can prevent
adhesion around the nerve and ameliorate nerve gliding, thus improving the functional recovery of the nerve
(22,23,24,25). Even though the mechanism still remains uncertain, the autologous vein graft has been found to
create fewer adhesions between the vein and the nerve compared with vein allografts. The inhibition of scar
formation around the nerve further has been confirmed by human histopathologic analysis from reexploration of
autologous vein-grafted nerves. These biopsies also revealed neovascularization of the vein graft with structural
transformation of the vein endothelium (26,27).
Indications
Recalcitrant carpal tunnel syndrome in patients with at least two previous operations that failed to resolve
the symptoms
Patients with significant nerve scarring or neuroma formation
Contraindications
Patients with chronic lower extremity venous insufficiency
A consultation by a vascular surgeon is recommended in patients with peripheral vascular disease or deep
venous thrombosis history. The saphenous vein is a major source of vein grafts in reconstructive and cardiac
surgery, and this should be taken into consideration in patients with coronary heart disease.
Technique
The autologous vein wrapping procedure is performed under general anesthesia because two operating fields
are required, one in the upper extremity for the median nerve reexploration and another in the lower extremity for
the harvesting of the saphenous vein. This procedure involves median nerve repeated decompression with
neurolysis, harvesting the saphenous vein of the lower extremity, preparing the vein properly, and then wrapping
the vein around the compressed nerve segment.
The affected median nerve is surgically explored first and is released from the surrounding scar tissue as
described above (Fig. 19-6). The dissection should always begin in virgin tissues and traced distally. If excessive
scarring is noted, an internal neurolysis is performed under the microscope. It is important to measure the length
of the segment of the median nerve that has to be vein wrapped. The required length of the vein graft is four to
five times the scarred length of the nerve. Usually, a vein graft length of 25 to 30 cm is needed.
The greater saphenous vein graft is harvested from the ipsilateral or contralateral lower extremity. The vein graft
can be harvested with a vein stripper to minimize the length of the incision (Fig. 19-7). A longitudinal incision
(approximately 2 cm long) is made 1 cm anterior to the medial
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malleolus, and the greater saphenous vein is identified. Care is taken to avoid injury of the saphenous nerve.
The saphenous vein is ligated distally, and through a small phlebotomy, the vein stripper is introduced and is
advanced proximally within the vein. The vein stripper can be palpated through the skin as it is advanced to the
predetermined length. At that point, a second incision is made over the stripper proximally and the vein is ligated
proximally. The vein graft is retrieved by slowly pulling out the stripper. The skin is closed, and the leg tourniquet
is deflated.
FIGURE 19-6 Excessive cicatrix (black arrows) around the median nerve during revision decompression in
patient with two previous procedures.
FIGURE 19-7 Harvesting of greater saphenous vein graft in the lower extremity using a vein stripper. K, knee;
MM, medial malleolus.
The vein graft is incised and opened longitudinally. With the intima of the vein graft against the nerve, one end
of the graft is tacked distal to the scarred segment of the median nerve on an immobile tissue. The vein graft is
circumferentially wrapped around the exposed median nerve from distal to proximal using a loose 7-0 Prolene
stitch to stabilize each loop of the vein with the adjacent loop (Fig. 19-8). Wrapping should not be too snug. The
other end of the vein graft is tacked proximal to the scarred segment of the median nerve on unscarred tissue.
Care is taken to cover completely the length of the segment of the scarred nerve to prevent recurrence of the
scarring (Fig. 19-9). The tourniquet is deflated, meticulous hemostasis is obtained, and routine closure is
performed.
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FIGURE 19-8 Wrapping the median nerve with autologous saphenous vein graft in a distal to proximal direction
with its intima against the nerve. Each ring of the wrapped vein is tacked to the adjacent rings with a 7-0 Prolene
suture.
FIGURE 19-9 The entire scarred portion of the median nerve is covered with the vein graft.
Pearls and Pitfalls

The length of the greater saphenous vein graft must be at least four times the scarred length of the median
nerve.
The use of vein stripper can minimize the length of the incision and the morbidity of the donor site.
The vein graft is opened longitudinally and is circumferentially wrapped around the exposed median nerve
from distal to proximal with the intima against the nerve.
The entire segment of the scarred nerve must be completely covered with the vein graft to prevent recurrence.
The wrist is immobilized in slight extension for 2 weeks postoperatively. Active and passive range-of-motion
exercises are started after the splint is removed. Scar massage, desensitization, and strengthening exercises can
also be initiated, if required. Heavy lifting is to be avoided for 6 weeks postoperatively.
Complications
This procedure is well tolerated in most individuals; however, transient leg swelling at the donor site (up to
6-month duration) can be noted due to the saphenous vein graft harvesting.
Results
The use of the autologous vein wrapping technique in patients with recalcitrant carpal tunnel syndrome has
been showed to be an effective treatment method in several clinical studies (28,29,30). Improvement of
pain, grip strength, and two-point discrimination were noted in the majority of
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patients. Electrodiagnostic studies postoperatively revealed improvement of findings in several patients,
although they did not return to normal values.
In the senior author's (D.G.S.) personal series, even after the initial clinical studies, consistently good
results with the autologous vein wrapping technique have been noted in more than one hundred patients
with recurrent carpal tunnel syndrome.
XENOGRAFT NERVE WRAPPING

Synthetic nerve wraps can be used in treatment of recurrent carpal tunnel syndrome. Xenograft wraps can
function as an adhesion barrier isolating the nerve from the surrounding tissues and preventing scar reformation
(31). Currently, there are available synthetic devices from porcine extracellular matrix (AxoGuard, AxoGen Inc.,
Alachua, FL) and bovine collagen (NeuraWrap, Integra LifeSciences, Plainsboro, NJ). These nerve wraps can
decrease the operative time, eliminate donor site morbidity, and overcome the limited availability of autologous
vein grafts. However, there are no sufficient clinical data to show whether these xenograft nerve wraps are better
than autologous vein nerve wraps.
Indications
Recalcitrant carpal tunnel syndrome
Contraindications
Patients with allergy to synthetic material.
The cost of xenograft nerve wrap may be considered a relative contraindication at some facilities.
Technique
The procedure is performed under regional or general anesthesia and tourniquet control. Revision
decompression of the affected median nerve is performed as described above (Fig. 19-10). Once the neurolysis
is completed, the xenograft nerve wrap is implanted around the nerve. The nerve wrap is secured around the
decompressed segment of the median nerve using horizontal mattress sutures with 7-0 Prolene (Fig. 19-11).
Attention is paid to completely cover all the length of the segment of the scarred nerve to prevent scar
reformation. After tourniquet deflation and meticulous hemostasis, a routine skin closure is performed.
FIGURE 19-10 Scarred median nerve (black arrows) during revision decompression in patient with one previous
procedure.
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FIGURE 19-11 Wrapping of the scarred median nerve with porcine extracellular matrix nerve wrap (blue arrows).
Prolene sutures marked with black arrows.
Pearls and Pitfalls

The xenograft nerve wrap is trimmed to the appropriate size in length and diameter (approximately 2 mm larger
that the nerve's diameter).
The xenograft nerve wrap is secured to itself around the nerve using horizontal mattress sutures.
Care is taken to avoid suturing the xenograft nerve wrap to the nerve.
The entire segment of scarred nerve must be completely covered to prevent recurrence.
The wrist is immobilized in slight extension for 2 weeks postoperatively. Active and passive range-of-motion
exercises are started after the splint is removed. Scar massage, desensitization, and a strengthening program
are recommended, if required.
Complications
As with all xenografts, there is a potential complication of immunologic reaction. Thus far, there have been
no reports on immune reactions or infection with this technique. Disadvantages of all xenografts include
cost and availability.
Results
The senior author (D.G.S.) has treated 16 patients with recurrent carpal tunnel syndrome with one previous
decompression with repeated decompression of the median nerve combined with porcine extracellular
matrix nerve wrap and coverage with hypothenar fat pad flap. All patients have shown clinical improvement
of the symptoms with significant relief of pain and increase in grip strength at a mean follow-up of 25 months
(range, 12 to 45 months). Sensation, two-point discrimination, and electrodiagnostic findings were also
improved. No complications or adverse reactions related to the xenograft nerve wrap were noted. However,
long-term clinical outcomes of the use of this xenograft nerve wrap are still pending.
SUMMARY
In patients with recurrent carpal tunnel syndrome, based on the senior author's (D.G.S.) clinical experience,
revision decompression of the median nerve should always be performed in combination with an ancillary
technique to enhance scar-free healing of the nerve. Our management algorithm for patients with one
previous decompression and absence of severe scar tissue is to perform revision decompression and
external neurolysis with xenograft nerve wrap and coverage with a hypothenar fat pad flap. If excessive scar
tissue is present during the repeated decompression and/or two or more previous surgeries have been
performed, we perform repeated neurolysis of the median nerve (external as well as possible internal,
epineurotomy with gentle internal neurolysis only if necessary) with autologous vein wrapping and coverage
with hypothenar fat pad flap.
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REFERENCES
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population. JAMA 282: 153-158, 1999.
2. Stutz N, Gohritz A, van Schoonhoven J, et al.: Revision surgery after carpal tunnel release-analysis of the
pathology in 200 cases during a 2 year period. J Hand Surg Br 31: 68-71, 2006.
3. Cobb TK, Amadio PC, Leatherwood DF, et al.: Outcome of reoperation for carpal tunnel syndrome. J Hand
Surg Am 21: 347-356, 1996.
4. Gelberman RH, Pfeffer GB, Galbraith RT, et al.: Results of treatment of severe carpal-tunnel syndrome
without internal neurolysis of the median nerve. J Bone Joint Surg Am 69: 896-903, 1987.
5. Hunter JM: Recurrent carpal tunnel syndrome, epineural fibrous fixation, and traction neuropathy. Hand
Clin 7: 491-504, 1991.
6. Milward TM, Stott WG, Kleinert HE: The abductor digiti minimi muscle flap. Hand 9: 82-85, 1977.
7. Reisman NR, Dellon AL: The abductor digiti minimi muscle flap: a salvage technique for palmar wrist pain.
Plast Reconstr Surg 72: 859-865, 1983.
8. Wilgis EF: Local muscle flaps in the hand. Anatomy as related to reconstructive surgery. Bull Hosp Joint
Dis Orthop Inst 44: 552-557, 1984.
9. Dellon AL, Mackinnon SE: The pronator quadratus muscle flap. J Hand Surg Am 9: 423-427, 1984.
10. Rose EH, Norris MS, Kowalski TA, et al.: Palmaris brevis turnover flap as an adjunct to internal
neurolysis of the chronically scarred median nerve in recurrent carpal tunnel syndrome. J Hand Surg Am 16:
191-201, 1991.
11. Tham SK, Ireland DC, Riccio M, et al.: Reverse radial artery fascial flap: a treatment for the chronically
scarred median nerve in recurrent carpal tunnel syndrome. J Hand Surg Am 21: 849-854, 1996.
12. Coleman SS, Anson BJ: Arterial patterns in the hand based upon a study of 650 specimens. Surg
Gynecol Obstet 113: 409-424, 1961.
13. Zancolli EA, Angrigiani C: Posterior interosseous island forearm flap. J Hand Surg Br 13: 130-135, 1988.
14. Page R, Chang J: Reconstruction of hand soft-tissue defects: alternatives to the radial fasciocutaneous
flap. J Hand Surg Am 31: 847-856, 2006.
15. Wintsch K, Helaly P: Free flap of gliding tissue. J Reconstr Microsurg 2: 143-150, 1986.
16. Strickland JW, Idler RS, Lourie GM, et al.: The hypothenar fat pad flap for management of recalcitrant
carpal tunnel syndrome. J Hand Surg Am 21: 840-848, 1996.
17. Mathoulin C, Bahm J, Roukoz S: Pedicled hypothenar fat pad flap for median nerve coverage in
recalcitrant carpal tunnel syndrome. Hand Surg 5: 33-40, 2000.
18. Plancher KD, Idler RS, Lourie GM, et al.: Recalcitrant carpal tunnel. The hypothenar fat pad flap. Hand
Clin 12: 337-349, 1996.
19. Chrysopoulo MT, Greenberg JA, Kleinman WB: The hypothenar fat pad transposition flap: a modified
surgical technique. Tech Hand Up Extrem Surg 10: 150-156, 2006.
20. Craft RO, Duncan SF, Smith AA: Management of recurrent carpal tunnel syndrome with microneurolysis
and the hypothenar fat pad flap. Hand (N Y) 2: 85-89, 2007.
21. Fusetti C, Garavaglia G, Mathoulin C, et al.: A reliable and simple solution for recalcitrant carpal tunnel
syndrome: the hypothenar fat pad flap. Am J Orthop 38: 181-186, 2009.
22. O'Brien JP, Mackinnon SE, MacLean AR, et al.: A model of chronic nerve compression in the rat. Ann
Plast Surg 19: 430-435, 1987.
23. Sotereanos DG, Xu J: Vein wrapping for the treatment of recurrent carpal tunnel syndrome. Tech Hand
Up Extrem Surg 1: 35-40, 1997.
24. Xu J, Sotereanos DG, Moller AR, et al.: Nerve wrapping with vein grafts in a rat model: a safe technique
for the treatment of recurrent chronic compressive neuropathy. J Reconstr Microsurg 14: 323-330, 1998.
25. Xu J, Varitimidis SE, Fisher KJ, et al.: The effect of wrapping scarred nerves with autogenous vein graft
to treat recurrent chronic nerve compression. J Hand Surg Am 25: 93-103, 2000.
26. Chou KH, Papadimitriou NG, Sarris I, et al.: Neovascularization and other histopathologic findings in an
autogenous saphenous vein wrap used for recalcitrant carpal tunnel syndrome: a case report. J Hand Surg
Am 28: 262-266, 2003.
27. Vardakas DG, Varitimidis SE, Sotereanos DG: Findings of exploration of a vein-wrapped ulnar nerve:
report of a case. J Hand Surg Am 261: 60-63, 2001.
28. Sotereanos DG, Giannakopoulos PN, Mitsionis GI, et al.: Vein graft wrapping for the treatment of
recurrent compression of the median nerve. Microsurgery 16: 752-756, 1995.
29. Varitimidis SE, Riano F, Vardakas DG, et al.: Recurrent compressive neuropathy of the median nerve at
the wrist: treatment with autogenous saphenous vein wrapping. J Hand Surg Br 25: 271-275, 2000.
30. Varitimidis SE, Vardakas DG, Goebel F, et al.: Treatment of recurrent compressive neuropathy of
peripheral nerves in the upper extremity with an autologous vein insulator. J Hand Surg Am 26: 296-302,
2001.
31. Kokkalis ZT, Pu C, Small GA, et al.: Assessment of processed porcine extracellular matrix as a protective
barrier in a rabbit nerve wrap model. J Reconstr Microsurg 27: 19-28, 2011.
Chapter 20
Thumb Opponensplasty
Ashraf M. Youssef
Colleen Davis
Kevin J. Malone
“A great asset to man is the opposable thumb. The hand (is) so useful to all and the livelihood of the manual
worker owes much of its efficiency to this pincer action of the thumb.”
—Sterling Bunnell, 1938
INTRODUCTION
Thumb opposition is a complex multiplanar movement performed by median nerve innervated muscles. It is often
confused with thumb apposition, which is simply placing the thumb in contact with the fingers. True opposition,
however, involves placing the thumb forward to the fingers out of the plane of the palm and with the pulp of the
thumb facing the pulp of the fingers (Fig. 20-1). This is achieved by a combination of three distinct movements of
the thumb ray: metacarpal palmar abduction, metacarpal pronation, and metacarpophalangeal (MCP) joint
flexion. This movement is coordinated through contraction of the abductor pollicis brevis (APB), flexor pollicis
brevis (FPB), and opponens pollicis (OP) with APB being the most important of the three.
Thumb opponensplasty involves restoration of thumb opposition via transfer of a functional, expendable,
extrinsic, or intrinsic muscle-tendon unit to the thumb ray to compensate for the functional loss of the thenar
muscles.
ANATOMY
A thorough understanding of median nerve anatomy is necessary to properly diagnose and treat median nerve
palsies (Fig. 20-2). Below is the classically described innervation pattern of the median nerve; however,
significant overlap with the ulnar nerve does exist, particularly with the musculature of the hand. Multiple
anatomic studies describe pure median, pure ulnar, and dual median/ulnar innervations of each of the thenar
muscles. This is supported by the fact that FPB remains functional in 73% of complete median and 58% of
complete ulnar nerve injuries.
The median nerve is composed of fibers from the medial and lateral cords of the brachial plexus.
The median nerve enters the forearm through the two heads of pronator teres and travels to the wrist between
flexor digitorum superficialis (FDS) and flexor digitorum profundus (FDP).
The anterior interosseous nerve (AIN) branches from the median nerve at the level of pronator teres and
innervates flexor pollicis longus (FPL), FDP to the index and long fingers, and pronator quadratus (PQ).
Proximal to the AIN branch, the median nerve innervates pronator teres, flexor carpi radialis, palmaris longus,
and FDS.
Distal to the AIN branch, the median nerve passes through the carpal tunnel and innervates APB, OP, and
FPB via the recurrent motor branch. Additionally, the first and second lumbricals are also innervated by the
median nerve.
It is essential that one be familiar with variations in the origin and course of the recurrent motor branch of the
median nerve to avoid iatrogenic injury during procedures around the wrist. Common variations with their
approximate incidences include the following:
Greater than 50%—originates distal to the carpal tunnel or within the carpal tunnel exiting distally beneath
the transverse carpal ligament (TCL)
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25%—pierces through the TCL
10%—exits the carpal tunnel ulnarly distal to the TCL and then travels radially to the thenar compartment
volar to the TCL
Another variation that one must be familiar with is a potential communicating motor branch between the
median and ulnar nerves.
Martin-Gruber anastomosis: approximately 10% to 44% of individuals. Motor fibers from proximal median
nerve or AIN travel to ulnar nerve in the forearm.
Riche-Cannieu anastomosis: present in approximately 77% of individuals. Motor fibers from the deep motor
branch of ulnar nerve in the hand travel to the median nerve.
FIGURE 20-1 Hand demonstrating thumb opposition. The thumb is abducted and rotated with MCP flexion. The
nail plate of the thumb is parallel to the nail plates of the fingers. (From Rayan GM, Akelman E: The hand:
anatomy, examination, and diagnosis. Philadelphia, PA: Lippincott Williams & Wilkins, 2011.)
FIGURE 20-2 The anatomic course and branches of the median nerve. (From Leversedge FJ, Boyer MI,
Goldfarb CA: A pocketbook manual of hand and upper extremity anatomy: primus manus. Philadelphia, PA:
Low median nerve palsy is defined as a lesion of the median nerve proper distal to AIN branch. Conversely, high
median nerve palsy involves a lesion of the median nerve proximal to the
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branching of the AIN therefore manifesting with loss of both median nerve and AIN innervated muscle function
(Fig. 20-3).
FIGURE 20-3 The branching and muscle innervation pattern of the median and anterior interosseous nerves. A
median nerve lesion proximal to the AIN branch is defined as a high median nerve palsy while a lesion distal to
the branching of the AIN is defined as a low median nerve palsy.
Low median nerve palsy leads to loss of thumb opposition. Paralysis of the first and second lumbricals is also
present but usually clinically insignificant if the ulnar nerve is intact as their function can be compensated by
the ulnar nerve innervated interossei muscles.
High median nerve palsies includes the above deficits in addition to loss of some or all of the following:
Forearm pronation—as PQ is innervated by the AIN.
Thumb and index finger flexion—as FDP to the index finger and FPL are innervated by the AIN.
Long-finger flexion—loss of long-finger flexion is more variable than is loss of index finger flexion as FDP to
the long finger often has dual innervation from the AIN and ulnar nerve. It may receive sole innervation from
the ulnar nerve in up to 50% of individuals.
INDICATIONS
Opponensplasty is indicated for loss of thumb opposition in the setting of a stable and supple thumb ray.
Although exceedingly rare today due to vaccination, polio has historically been the most common indication
for thumb opponensplasty. Common indications today include loss of thumb opposition due to:
Chronic median nerve entrapment neuropathies resulting in thenar atrophy
Median nerve injury
Muscular dystrophies
Loss of the thenar musculature due to infection or trauma
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CONTRAINDICATIONS
Opponensplasty will be unsuccessful if performed in the setting of a first web space contracture. The
contracture must first be addressed with therapy, splinting, and/or surgery.
Noncorrectable instability or contracture in any joints of the thumb ray precludes opponensplasty.
While there are few absolute contraindications to opponensplasty, one must adhere to the general principles for
tendon transfers.
Full passive range of motion must be present or established prior to transfer.
Tendon transfers should not be performed in the setting of an open wound.
The donor muscle must be of sufficient strength and its primary function expendable.
The donor tendon must be of sufficient length and travel in-line with the force vector of its new desired
function after transfer.
Choosing a donor muscle with synergistic function to the one(s) being replaced will facilitate postoperative
rehabilitation.
The hand and fingers must be assessed for adequate range of motion. Contractures and joint stiffness are
common in long-standing median nerve palsies. These can be prevented preoperatively with appropriate
splinting and therapy. Once contractures have developed, they must be corrected prior to opponensplasty with
aggressive therapy, splinting, and/or surgical release.
Dorsal skin contractures of the first web space that fail to respond to splinting can be addressed with Z-plasty
or a dorsal rotational flap with skin grafting.
All soft-tissue wounds should be stable. Ideally, the tendon transfer should pass through uninjured supple
tissues to minimize potential of tendon adhesions.
Contracture of the carpometacarpal (CMC) joint capsule can lead to isolated loss of thumb pronation. This can
often be treated with thumb CMC capsulotomy.
Severe contractures and those that fail to respond to the above treatments may be treated with metacarpal
osteotomy and/or trapeziectomy.
The interphalangeal (IP) joint of the thumb must be stable and capable of extension to neutral to provide a
stable post for pinch grip. Repair or tenodesis of the EPL tendon or fusion of the IP joint should be performed
if necessary.
Strength and functional excursion of the flexors and extensors of the wrist and fingers must be examined in order
to determine the musculotendinous units available for transfer.
The function of the donor motor unit must be expendable.
The donor motor unit must be of sufficient strength preoperatively. The transferred unit will lose one grade of
strength on the Oxford scale after transfer (Table 20-1).
The length of the donor motor unit is also of key importance. An ideal donor tendon should comfortably reach
the thumb MCP joint without lengthening, grafting, or overtensioning. It is challenging to set appropriate
tension through a lengthened system or graft, and overtensioning may adversely affect the power by altering
the length-tension relationship of the muscle.
Finally, proper patient selection and education are paramount to success. A technically well-performed transfer
will lead to poor outcomes in a patient who is noncompliant with the postoperative therapy. Furthermore,
excellent objective outcomes do not preclude poor subjective outcomes in a patient with unrealistic expectations.
TABLE 20-1 Oxford Scale for Grading Muscle Strength
Grade Maximum Muscle Force Generation
0/5 Flaccid, no muscle contraction
1/5 No movement, but visible or palpable muscle contraction
2/5 Movement with gravity eliminated (parallel to floor)
3/5 Movement against gravity (vertical away from floor)
4/5 Weak; movement with some resistance
5/5 Full strength, movement with full resistance

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The surgeon must have a detailed discussion with the patient on what is reasonable to expect in terms of
potential functional recovery.
The discussion must stress the need for participation in a lengthy, structured postoperative rehabilitation plan
such as the one outlined in the therapy section of this chapter. A patient who is unable or unwilling to actively
participate in pre- and postoperative therapy should be discouraged from undergoing opponensplasty.
TECHNIQUE
There is no agreed-upon “best” technique for opponensplasty for low median nerve palsy. Four common
techniques are listed in Table 20-2 and described below. The FDS to the ring finger appears to be the most
commonly used technique; however, transfer of the extensor indicis proprius (EIP) tendon is becoming more
popular because it does not weaken the patients grip and leaves little to no functional deficit. One study by
Anderson suggests that FDS is better suited for stiffer hands while EIP performed better in more supple hands.
The Huber technique has the unique benefit of cosmesis as the bulk of the transferred unit somewhat restores
the appearance of a thenar compartment. For this reason, it is often used in pediatric cases. The Camitz
technique restores the least amount of function but is a relatively simple procedure that can be performed in
severe cases of carpal tunnel syndrome at the time of carpal tunnel release through an extended incision.
Opponensplasty for high median nerve palsy is treated in the same manner as a low palsy; however, the
additional deficits must also be addressed, specifically loss of thumb IP, index, and long finger flexion as well as
forearm pronation. The FDS transfer is not available as a donor motor unit in high median nerve palsy.
Thumb IP flexion can be restored via transfer of the brachioradialis tendon to the FPL tendon.
Index finger and long finger flexion can be restored by transferring their respective FDP tendons to the FDP
tendons of the small and ring fingers.
Forearm pronation can be restored via biceps rerouting around the radius.
TABLE 20-2 Common Donor Muscle Choices for Opponensplasty
Donor Eponym Advantages Disadvantages

Muscle
Flexor Riordan Excellent tendon length. Sufficient muscular Can be associated

digitorum strength and excursion with swan-neck
superficialis deformity of the PIP
(ring finger) joint
Palmaris Camitz Often done at the same time as carpal Often requires
longus tunnel release and therefore requires no extension using a
other incision to harvest the donor tendon tendon graft or the
palmar fascia
Extensor Burkhalter Excellent in combined median/ulnar palsies Index finger MCP joint
indicis contracture
proprius
Abductor digiti Huber Recreates the contour of the thenar Tenuous blood supply
minimi eminence may lead to fibrosis
Patient Positioning
For all techniques, the patient is positioned supine on the operating room table with the arm abducted to 90
degrees on a hand table.
All techniques may be performed with a nonsterile tourniquet placed around the brachium.
Flexor Digitorum Superficialis to the Ring Finger (Riordan)

Make a transverse skin incision over the distal palmar crease at the base of the ring finger.
Bluntly dissect down to the A1 pulley, and identify and protect the radial and ulnar neurovascular bundles.
Longitudinally incise the A1 pulley and isolate the FDS tendon by observing proximal interphalangeal (PIP)
joint flexion with traction. Traction to the FDP tendon should cause distal interphalangeal joint flexion with the
PIP held in extension.
Transversely incise the FDS tendon just proximal to its bifurcation taking care to protect the FDP tendon as
well as the radial and ulnar neurovascular bundles.
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Next, make a zigzag skin incision centered over the flexor carpi ulnaris (FCU) tendon site at the wrist flexor
crease between the palmaris longus and pisiform.
Isolate the FCU tendon. Identify and protect the ulnar artery and nerve and dissect the distal 4 to 5 cm of the
tendon free from the surrounding soft tissue. Take care not to detach the tendon from its insertion on the
pisiform.
Using a No. 11 blade, longitudinally split the distal 4 cm of the tendon in the midline.
Divide the radial half of the tendon at the proximal aspect of the split. Bring the free end distally and suture it to
the intact FCU insertion site on the pisiform using 4-0 braided suture thereby creating a loop to be used later
as a pulley for the transferred FDS tendon (Fig. 20-4).
Make a 4-cm skin incision at the dorsal-radial aspect of the thumb MCP joint. Bluntly dissect down to the joint
capsule. Take care to protect the branches of the superficial radial nerve and any large dorsal veins.
Using a large hemostat, create a subcutaneous tunnel between the proximal end of the thumb incision and the
distal forearm incision (Fig. 20-5).
Next, pass the FDS tendon through the FCU loop created earlier and then subcutaneously from the distal wrist
wound to the thumb wound using a tendon passer. Ensure that the tendon glides freely along its new course
(Fig. 20-6).
With the wrist in neutral, move the thumb into full opposition with the small finger.
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While an assistant holds the thumb in place, suture the transferred tendon to the APB insertion site as well as
the joint capsule with 4-0 braided suture. The graft should be tensioned to approximately 75% of maximal
excursion. The wrist can be flexed 30 degrees if needed to achieve adequate tendon length and ease of
suturing after the set point is determined.
Deflate the tourniquet and obtain hemostasis with bipolar electrocautery. Local or regional anesthesia may be
considered for postoperative pain control.
Irrigate the wounds, and close the incisions with everted skin edges using interrupted 4-0 nylon sutures.
Apply nonadherent wound coverage and place the thumb in a well-padded thumb spica splint with the IP joint
free. The splint should be molded to keep the thumb in midrange opposition.
FIGURE 20-4 The incised portion of FCU tendon is looped down and sutured to its insertion site to create a
pulley for the transferred FDS tendon. The released FDS tendon to the ring is seen at the top of the image.
(From Wiesel SW: Operative techniques in orthopaedic surgery. Philadelphia, PA: Lippincott Williams & Wilkins,
2010.)
FIGURE 20-5 The FDS tendon is passed through the FCU pulley and then through the subcutaneous tunnel in
the distal forearm incision to the base of the thumb. (From Wiesel SW: Operative techniques in orthopaedic
surgery. Philadelphia, PA: Lippincott Williams & Wilkins, 2010.)
FIGURE 20-6 A large hemostat is used to create a subcutaneous tunnel between the distal forearm and thumb
incisions. (From Wiesel SW: Operative techniques in orthopaedic surgery. Philadelphia, PA: Lippincott Williams
& Wilkins, 2010.)
Extensor Indicis Proprius (Burkhalter)

Make a longitudinal incision on the dorsum of the index finger MCP joint and isolate the EIP tendon, which can
be found deep and ulnar to the extensor digitorum communis (EDC) tendon (Fig. 20-7).
Divide the EIP tendon at the proximal edge of the extensor hood. Take care to protect the EDC tendon to the
index finger.
Make a long longitudinal incision on the dorsal ulnar aspect of the wrist just proximal to the ulnar styloid taking
care not to injure the dorsal sensory branch of the ulnar nerve.
Bluntly dissect subcutaneously and radially until the proximal EIP tendon can be identified.
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Retrieve the EIP tendon proximal to the extensor retinaculum through the ulnar wrist wound. A small incision
can be made over the dorsum of the wrist to isolate the tendon and divide any connections between EIP and
the EDC to the index finger if needed. The fourth dorsal compartment can be divided longitudinally if needed
to completely free the EIP tendon from any connections (Fig. 20-8).
Free any soft-tissue attachments to the EIP muscle and tendon in the distal third of the forearm.
Next, make a small longitudinal incision over the pisiform and another 4-cm incision over the dorsal-radial
aspect of the thumb MCP joint.
Bluntly create a subcutaneous tunnel from the ulnar wrist incision to the pisiform incision and then onto the
thumb MCP joint incision, using a large hemostat.
Pass the EIP tendon from the ulnar wrist incision first to the pisiform incision and then onto the thumb incision
(Figs. 20-9 and 20-10). Ensure that the tendon passes superficial to the FCU tendon to prevent ulnar nerve
compression.
The transferred tendon is then sutured in place, the wounds closed, and the hand and wrist splinted as
described above in the FDS transfer technique.
FIGURE 20-7 Isolation of EIP tendon over the index MCP joint. EIP is located deep and ulnar to the EDC tendon
to the index finger. (From Wiesel SW: Operative techniques in orthopaedic surgery. Philadelphia, PA: Lippincott
FIGURE 20-8 EIP is located and isolated on the dorsum of the wrist distal to the extensor retinaculum. The fourth
dorsal compartment can be released longitudinally if needed. (From Wiesel SW: Operative techniques in
orthopaedic surgery. Philadelphia, PA: Lippincott Williams & Wilkins, 2010.)
FIGURE 20-9 The EIP tendon is passed from the dorsal ulnar wrist incision to the palmar incision over the
pisiform. The EIP muscle belly is freed of any softtissue connections. (From Wiesel SW: Operative techniques in
orthopaedic surgery. Philadelphia, PA: Lippincott Williams & Wilkins, 2010.)
FIGURE 20-10 The EIP tendon is passed through the palmar subcutaneous tunnel from the incision over the
pisiform to the base of the thumb. (From Wiesel SW: Operative techniques in orthopaedic surgery. Philadelphia,
PA: Lippincott Williams & Wilkins, 2010.)
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Adductor Digiti Minimi (Huber)
Make a midlateral incision along the ulnar aspect of the small finger from the PIP joint to the distal palmar
crease. The incision is then continued proximally along the radial border of the hypothenar eminence to the
distal wrist crease (Fig. 20-11).
Divide the two insertions of abductor digiti minimi (ADM) at the base of the proximal phalanx and the lateral
band. A portion of the lateral band can be taken in continuity with the ADM to increase its length.
Separate ADM from its soft-tissue attachments distally to proximally to its origin on the pisiform (Fig. 20-12).
Take care to identify and protect its neurovascular pedicle located dorsally and radially on the proximal muscle
belly.
Alternatively, the ulnar nerve and artery can be identified proximally and traced distally to identify the pedicle.
Once the pedicle is identified, elevate ADM from its insertion on pisiform while maintaining its attachment to
the FCU tendon.
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Make a 4-cm skin incision at the dorsal-radial aspect of the thumb MCP joint. Bluntly dissect down to the joint
capsule. Take care to protect the branches of the superficial radial nerve and any large dorsal veins.
Using a large hemostat, create a subcutaneous tunnel between from the proximal end of the thumb incision to
the pisiform (Fig. 20-13).
Pass the ADM tendon subcutaneously to the thumb wound.
FIGURE 20-11 Skin incision from the ulnar aspect of the small finger PIP joint along the radial aspect of the
hypothenar eminence to the distal wrist crease. (From Waters PM, Bae DS: Pediatric hand and upper limb
surgery: a practical guide. Philadelphia, PA: Lippincott Williams & Wilkins, 2012.)
FIGURE 20-12 ADM is isolated and dissected free along its entire length to its origin. (From Wiesel SW:
Operative techniques in orthopaedic surgery. Philadelphia, PA: Lippincott Williams & Wilkins, 2010.)
FIGURE 20-13 Creation of subcutaneous tunnel from ulnar incision to base of thumb. (From Wiesel SW:
Operative techniques in orthopaedic surgery. Philadelphia, PA: Lippincott Williams & Wilkins, 2010.)
Palmaris Longus (camitz)

Confirm the presence of a palmaris longus preoperatively by having the patient attempt thumb and small finger
opposition with the wrist flexed.
Make a longitudinal zigzag incision from just proximal to the distal wrist crease to the proximal palmar crease.
Take care to identify and protect the palmar cutaneous branch of the median nerve, which runs just radial to
the palmaris longus tendon.
Bluntly dissect the PL tendon from proximal in the forearm to distally where it terminated into the palmar
aponeurosis.
Incise the aponeurosis taking 1-cm strip of palmar aponeurosis in continuity with the PL tendon.
Reflect the tendon graft and decompress the carpal tunnel.
Make an incision over the dorsal-radial aspect of the thumb MCP joint.
Bluntly create a subcutaneous tunnel between the wrist and thumb wounds using a hemostat.
Pass the PL tendon through the tunnel to the thumb wound.
Attaching the PL tendon more dorsally on the thumb at the EPB insertion site on the dorsal capsule may afford
slightly better opposition of the thumb.
PEARLS AND PITFALLS

If not proactively prevented with bracing from the time of injury, first web space contractures commonly occur
in patients with median nerve palsies. If present, this must be addressed prior to opponensplasty for a
successful result.
One must adhere to all the general principles of tendon transfer.
The patient must have a functionally significant deficit preoperatively to have a functionally successful
outcome postoperatively.
THERAPY AND POSTOPERATIVE MANAGEMENT

Preoperative Hand Therapy
Decrease web space contractures with stretching and splinting.
Increase PROM of all joints to promote a successful transfer.
Decrease edema and scar tissue with compression and scar conformers.
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Simulate transfer and strengthen the donor muscles:
Use sponges or dowels to simulate thumb abduction.
For FDS transfer:
Contract ring FDS with simultaneous relaxation of other digits.
Apply resistance to ring-finger PIP flexion.
For EIP transfer:
Contract EIP with other digits in composite flexion.
Apply resistance to index extension.
Educate the patient regarding realistic goals and expectations of outcome—strong grasp and pinch as well as
functional thumb opposition, not normal hand function.
Postoperative Hand Therapy

10 to 14 Days
Edema control—Ice, elevation, and Tubigrip/Coban compression
Splint—Forearm-based thumb spica splint
Wrist: 20 degrees of flexion

Thumb in wide palmar abduction directly under the index
3 to 4 Weeks
Scar management:
Use back of eraser or Dycem to gently mobilize scar.

Scar conformers with compression at night.
AROM:
Thumb extension/flexion, adduction/flexion, and opposition to each digit

Limit full thumb radial abduction
Blocking and tendon gliding of uninvolved digits
Splint: May remove for wrist AROM
4 Weeks
Function:
Light prehensile activities with emphasis on wide palmar abduction
Place and hold
Short sessions with fewer reps of good contractions
Increase endurance
Proprioceptive neuromuscular facilitation techniques including hold, relax, and active motion
Mirror therapy
Strengthening:
Initiate progressive strengthening with sponge, putty, Nerf ball, and/or tennis ball.
Splint:
Discontinue forearm-based splint.
Provide hand-based thumb spica prefab splint.
8 to 12 Weeks
Splint:
Discontinue splinting.
Simulation of meaningful activities to reproduce various grip and pinch functions required for activities of daily
living and occupation/activity specific tasks
Strategies for Successful Outcome

Emphasis should be placed on prehensile activities throughout the course of therapy.
Keep in mind, the purpose of this transfer is to allow for palmar abduction of the thumb.
Typically, the patient does not achieve opposition and pronation of the thumb.
Pitfalls or causes for disappointment

Acceptance of less than full passive motion before transfer
Overestimation of the strength of the donor muscle
Adhesions preventing full tendon excursion
Technical failures:
Breakdown of juncture
Tendon transfer too tight or too loose
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COMPLICATIONS
Although complications do exist, the majority can be avoided with careful preoperative planning, patient
selection, and setting expectations in regard to the lengthy postoperative rehabilitation process.
Lack of thumb range of motion due to joint stiffness.
Inadequate opposition strength due to selection of a weak muscle-tendon unit for transfer.
Loss of original donor motor function due to poor selection of donor muscle-tendon unit (i.e., loss of grip
strength after FDS transfer).
PIP joint flexion or hyperextension contracture (for FDS transfers).
Difficulty with motor unit retraining. This is more difficult when nonsynergistic motor unit transfers (i.e., it
is more difficult to retrain an EIP transfer than an FDS transfer).
Tendon ruptures.
Tendon adhesions.
RESULTS
In general, opponensplasty is successful with most patients regaining adequate function to perform
activities of daily living. There is no agreed-upon superior technique, and all of the above are supported by
studies showing high rates of good/excellent results. The Huber technique does, however, have the unique
benefit of cosmetic appearance in situations where this is important. The outcomes are ultimately
dependent on proper patient selection and education as well as careful preoperative evaluation and
planning.
Jensen reported good opposition using an FDS technique in 22 of 27 cases.
Burkhalter reported excellent results in 57 of 65 trauma cases using EIP opponensplasty. The series was
composed of 32 combined median/ulnar, 13 high median, and 2 brachial plexus injuries.
Andersen used an EIP transfer in 12 high and 28 low median nerve palsies and reported excellent or
good results in 88% of cases.
Several authors describe the Huber technique to be technically difficult due to the tenuous blood supply
to the ADM and recommend that it be reserved only for cases where other simpler techniques are
contraindicated.
Many surgeons, however, consider the Huber technique as the opponensplasty of choice for congenital
thenar deficiencies given its cosmetic benefits.
Foucher reported a series of 73 Camitz procedures done at the time of carpal tunnel release for severe
carpal tunnel syndrome with 50% regaining good thumb opposition within 12 months. By 102 months,
91% had regained satisfactory, or better, thumb opposition.
RECOMMENDED READING
Anderson GA, Lee V, Sundararaj GD: Opponensplasty by extensor indicis and flexor digitorum superficialis
tendon transfer. J Hand Surg Br 17B: 611-614, 1992.
Brandsma JW, Ottenhoff-De Jonge MW: Flexor digitorum superficialis tendon transfer for intrinsic
replacement. Long-term results and the effect on donor fingers. J Hand Surg Br 17B: 625-628, 1992.
Bunnell S: Opposition of the thumb. J Bone Joint Surg 20: 269-284, 1938.
Burkhalter W, Christensen RC, Brown P: Extensor indicis proprius opponensplasty. J Bone Joint Surg 55A:
725-732, 1973.
Cannon NM, Schnitz G: Diagnosis and treatment manual for physicians and therapists. 4th ed. Indianapolis,
IN: The Hand Rehabilitation Center of Indiana, 2001.
Davis TRC: Median and ulnar nerve palsy. In: Wolfe SW, Hotchkiss RN, Pederson WC, Kozin SH, eds.
Green's operative hand surgery. 6th ed. Philadelphia, PA: Churchill Livingstone, 2011: 1093-1115.
Foucher G, Malizos C, Sammut D: Primary palmaris longus as an opponensplasty in carpal tunnel release. J
Hand Surg Br 16: 56-60, 1991.
Hunter JM, Mackin EJ, Callahan AD, et al.: Rehabilitation of the hand and upper extremity. 5th ed. St. Louis,
MO: Mosby, 2002: 779-879.
Jacobs B, Thompson TC: Opposition of the thumb and its restoration. J Bone Joint Surg 42A: 1015-1026,
1960.
Jenson EG: Restoration of opposition of the thumb. Hand 10: 161-167, 1978.
Lee DH, Oakes JE: Tendon transfers for thumb opposition: a biomechanical study of pulley location and two
insertion sites. J Hand Surg Br 28A: 1002-1008, 2003.
Mackinnon SE, Novak CB: Compression neuropathies. In: Wolfe SW, Hotchkiss RN, Pederson WC, Kozin
SH, eds. Green's operative hand surgery. 6th ed. Philadelphia, PA: Churchill Livingstone, 2011: 985-996.
Oberlin C, Touam C, Bhatia A: Opponensplasty. Tech Hand Up Extrem Surg 3: 131-138, 1999.
Omer GE Jr: Tendon transfers for combined traumatic nerve palsies of the forearm and hand. J Hand Surg
Br 17B: 603-610, 1992.
Omer GE Jr: Tendon transfers for traumatic nerve injuries. J Am Soc Surg Hand 4: 214-226, 2004.
Ratner JA, Peljovich A, Kozin SH: Update on tendon transfers for peripheral nerve injuries. J Hand Surg Br
35A: 1371-1381, 2010.
Royle ND: An operation for paralysis of the intrinsic muscles of the thumb. JAMA 111: 612-613, 1938.
Skie MC, Parent T, Mudge K, et al.: Kinematic analysis of six different insertion sites for FDS
opponensplasty. Hand 5: 261-266, 2010.
Thompson TC: A modified operation for opponens paralysis. J Bone Joint Surg 26: 632-640, 1942.
Chapter 21
Nerve Transfers for Median and Ulnar Nerve Injuries
Ryan D. Katz
Ebrahim Paryavi
INDICATIONS
Proximal motor nerve injuries can sometimes benefit from surgical intervention to restore function in the
upper extremity. It is generally accepted that the rate at which peripheral nerve growth occurs from the level
of neurorrhaphy is 1 mm per day.
Motor end-plate viability on the target musculature is limited to about 12 to 18 months without innervation
(1). Given the rate of peripheral nerve growth described above, motor end-plate viability is not assured in
any high median or ulnar nerve (UN) injury that may require more that 12 to 18 months for regenerating
axons to reach their target.
Thus, any surgical modality that decreases the time to motor end-plate reinnervation may be of potential
benefit to patients with high nerve injuries. Transfer of healthy peripheral nerve axons from an uninjured
nerve to an injured nerve, downstream from the site of injury, remains one such modality.
Distal nerve transfers to regain or preserve motor function may also be preferred in cases where there is
significant trauma resulting in extensive proximal scarring or significant nerve substance loss. Nerve
transfers in these settings ensure a healthy nerve-to-nerve coaptation and may preclude the need for a free
donor nerve graft (in which a normal sensory nerve is often sacrificed). In these situations, as compared to
traditional nerve grafting, transferring a motor nerve from outside of the zone of injury is technically easier
and has improved outcomes compared to nerve grafting and regeneration over long distances (2,3).
High Ulnar Nerve Injury
In the absence of an anatomic variation, high UN injuries result in significant hand dysfunction. These
injuries affect the ulnar extrinsic profundus flexors as well as the interossei and ulnar lumbricals. The motor
deficit from this injury often leads to clawing of the ring and small fingers, impaired dexterity, and decreased
hand strength. Disability from this injury can be limited by minimizing the time to motor end-plate
reinnervation and/or by preserving motor end plates during upstream nerve recovery. The distal anterior
interosseous nerve (AIN) to motor branch of the UN transfer offers this potential benefit (4).
High Median Nerve Injury
The motor deficit from a high median nerve (MN) injury is the result of loss of function of muscles innervated
by the AIN and recurrent motor branch of the MN. This causes impaired action of all the superficial flexors,
the radial-sided profundus flexors, impaired thumb interphalangeal joint
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flexion, and impaired thumb palmar abduction, pronation, and, as a result, opposition. The goal of surgical
treatment is to restore finger flexion and prehension (5). In cases where the musculocutaneous nerve
(MCN) is preserved, transfer of the brachialis branch to motor branches of the MN in the arm has proven to
be anatomically feasible and clinically effective (1,5,6).
CONTRAINDICATIONS
Nerve transfer is contraindicated in chronic nerve injuries in which the likelihood of target reinnervation is low. As
motor end-plate viability decreases with time, so too does the probability of operative success. Therefore,
attempts to regain native motor function 12 to 18 months after an injury should be discouraged.
Nerve transfer is also contraindicated in patients who cannot comply with a postoperative rehabilitation program
or in which the potential donor nerve may be injured or diseased. Ideally, the donor motor nerve strength should
be M4 or greater to maximize benefit (6).
GENERAL TECHNIQUES
Preoperative EMG to ensure viability of motor units in the target musculature is obtained.
The patient is placed supine on a well-padded table with the operative arm prepped and draped on a well-
padded hand table.
A tourniquet may be used to minimize bleeding and improve visualization. A sterile tourniquet can facilitate a
more proximal dissection if needed.
Intraoperative use of a nerve stimulator can be useful to aid in identification of recipient nerve targets (e.g.,
motor portion of UN) or prove the adequacy and specificity of proposed donor nerves (e.g., to identify the
anterior interosseous portion of the MN or to differentiate between the brachialis motor branch [BMB] of the
MCN from the lateral antebrachial cutaneous [LABC] branch of the MCN) (5,7).
A surgical microscope should be available in the operating room.
Fibrin glue is often used to expedite and augment the nerve coaptation.
All neurorrhaphies should be performed in a tension-free manner.
Distal Anterior Interosseous Nerve Transfer to Ulnar Nerve Motor Branch

An incision is made in the palm just ulnar to a traditional carpal tunnel approach.
This incision is carried proximally with a zigzag across the wrist flexion crease and extending approximately 8
to 10 cm from the crease in the ulnar third of the forearm (Fig. 21-1).
Dissection is carried out distally through the hypothenar fat to the hamate hook and volar carpal ligament.
The volar carpal ligament is incised, revealing the ulnar neurovascular bundle in Guyon's canal.
The motor branch of the UN is released around the hook of the hamate and traced proximally.
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Dissection proceeds proximally along the UN up to the takeoff of the dorsal ulnar sensory branch (Fig. 21-2).
The motor fascicular group of the UN can be reliably located immediately radial to the takeoff of the dorsal
ulnar sensory branch, lying between it and the sensory portion of the UN (Fig. 21-3).
The motor fascicular group is dissected free from the surrounding sensory portions of the nerve.
A vessel loop is placed around this group to facilitate later identification.
The finger flexor tendons are then retracted radially to reveal the pronator quadratus (PQ).
The distal anterior interosseous nerve is visualized entering the PQ at the proximal edge of the muscle (Fig.
21-4A,B).
The overlying fascia of PQ is incised, the muscle fibers taken down with a bipolar cautery, and the nerve is
traced as distally as possible through the muscle fibers (Fig. 21-5).
The nerve is transected distally where it begins to branch into the muscle.
Proximally, the nerve is freed from surrounding soft-tissue attachments to improve mobilization for the
subsequent transfer.
Proximal dissection should be performed as far as necessary to ensure a tension-free nerve coaptation that
can be performed without the need for graft.
The AIN is mobilized over and placed next to the previously identified target motor fascicular group of the UN
(Fig. 21-6A,B).
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More length and less tension can be achieved, if needed, by bringing the AIN between the UN and ulnar
artery rather than directly over the ulnar artery.
If an end-to-side neurorrhaphy is to be performed, a window is made in the nerve epineurium and perineurium.
Formation of the perineural window is facilitated by teasing apart the perineurium with micro forceps under the
operative microscope.
If an end-to-end coaptation is to be performed, the previously identified ulnar motor fascicular group is divided
proximally taking into account length required to achieve a tension-free neurorrhaphy.
After placing a preliminary microsuture at the proposed site of coaptation, a tension-free repair is ensured by
flexing and extending the wrist and fingers after repair while visualizing the neurorrhaphy site.
Formal coaptation of the nerves is carried out with 9-0 nylon suture under the microscope and can be
augmented with fibrin glue (Fig. 21-7).
FIGURE 21-1 Proposed incision extending in a “zigzag” fashion into the hand. This incision should be proximal
enough to allow visualization of the takeoff of the dorsal ulnar sensory nerve and distal enough to allow
decompression of Guyon's canal.
FIGURE 21-2 Dissection should be proximal enough to allow visualization of the takeoff of the dorsal ulnar
sensory nerve branch. This landmark will allow proper identification of the motor fascicular group of the UN. In
this picture, the dorsal ulnar sensory nerve branch can be seen at the top of the picture.
FIGURE 21-3 The motor fascicular group of the UN is reliably located immediately radial to the takeoff of the
dorsal ulnar sensory nerve branch. Here, the motor fascicular group has been isolated and tagged with a vessel
loop.
FIGURE 21-4 A,B: After retracting the flexor tendons radially, the PQ branch of the AIN is seen entering the
proximal edge of the muscle. A blue vessel loop has been placed demonstrating the AIN.
FIGURE 21-5 An intramuscular dissection allows the AIN to be traced distally through the PQ. Dissection ceases
once the AIN begins to branch within the muscle. The AIN is transected distally just proximal to its branches.
FIGURE 21-6 A,B: The AIN is draped in a tension-free manner on to the proposed site of coaptation. The
coaptation can be performed in an end-to-side or end-to-end fashion. A temporary stitch may be placed and the
wrist ranged to ensure no tension will exist at the repair site.
FIGURE 21-7 The AIN has been sutured to the motor fascicular group of the UN in an end-toside fashion.
Brachialis Motor Branch of Musculocutaneous Nerve (BMBMCN) Transfer to Anterior

Interosseous Nerve
A 10- to 15-cm medial longitudinal incision is made extending distally from the medial aspect of the upper arm
(Fig. 21-8).
The MCN is identified between the biceps brachii and brachialis muscles (Fig. 21-9).
The BMBMCN branch is identified approximately 13 cm proximal to the medial epicondyle (Fig. 21-10A,B).
A nerve stimulator may be used to confirm that this is the correct nerve as opposed to the LABC.
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This nerve is traced distally as far as possible prior to branching and divided (Fig. 21-11).
The MN is then identified medial to the MCN, in the same muscular interval (Fig. 21-12).
The BMBMCN is mobilized over to the MN to determine the length of MN required (Fig. 21-13).
The motor fascicles of the MN, which are located in the posterior third of the nerve, are dissected and
separated from the sensory components.
A nerve stimulator may be used to confirm that this portion of the MN corresponds to the motor fascicular
group.
This motor portion is divided proximally taking into consideration length required to achieve tension-free repair.
After placing a preliminary microsuture at the proposed site of coaptation, a tension-free repair is ensured by
fully ranging the elbow while visualizing the neurorrhaphy site.
Formal coaptation of the nerves is carried out with 9-0 nylon suture under the microscope and can be
augmented with fibrin glue (Fig. 21-14).
FIGURE 21-8 The proposed incision for the BMB of musculocutaneous nerve transfer (BMBMCN) to anterior
interosseous nerve. The incision should be approximately 10 to 15 cm long and is positioned over the biceps and
brachialis interval.
FIGURE 21-9 The MCN is identified under the biceps traveling along the brachialis.
FIGURE 21-10 A,B: The BMBMCN is identified branching from the MCN and entering the brachialis. This will be
approximately 13 cm proximal to the medial epicondyle.
FIGURE 21-11 The BMBMCN is traced as distally as possible and then divided.
FIGURE 21-12 The MN can be seen in the same muscular interval medial to the MCN. In this picture, the MCN
is above and the MN is below.
FIGURE 21-13 The BMBMCN is mobilized over to the MN to determine the potential site of coaptation.
FIGURE 21-14 The BMBMCN has been transferred to the motor fascicular group of the MN and a coaptation
performed in a tension-free manner.
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PEARLS AND PITFALLS (SPECIAL ADVICE FOR THE ADVANCED
TECHNIQUES FEATURED IN THIS SERIES)
A tension-free repair is of paramount importance in all nerve repairs to minimize scarring and maximize axonal
regeneration across the neurorrhaphy.
Fibrin glue may be used in addition or as an alternative to sutures for coaptation of nerves.
In 90% of arms, the BMBMCN follows a type I pattern, meaning that a single branch of the MCN innervates
the brachialis muscle. In the minority of cases with multiple MCN branches to the brachialis, the largest should
be selected and used as a transfer donor after confirmation with intraoperative stimulation.
Splints are applied for 5 to 7 days in a neutral position for the wrist in the case of AIN transfer and 90-degree
flexion of the elbow for BMBMCN transfer.
Early range of motion is initiated with the help of a therapist.
Targeted recruitment and reeducation of the nerve transfer is initiated 4 weeks postoperatively.
For AIN transfers, recruitment of the donor nerve focuses on pronation.

Elbow flexion is emphasized for the BMBMCN transfer.
COMPLICATIONS
AIN to Motor Branch of UN Transfer
Although donor morbidity is a concern in any nerve transfer, as discussed in the previous chapter, this has
not been shown to be a problem in practice for AIN transfers.
BMBMCN to AIN Transfer
In traumatic cases where the inferior trunk is injured and there is some involvement of the superior and
middle trunks, there may not be sufficient recovery of axons in the affected BMBMCN to innervate finger
flexors after transfer. This was observed in 1 of 6 cases reported by Zheng et al. (5) at 18-month final
follow-up. Quantifiable deficits in elbow flexion have not been observed clinically after the BMBMCN
transfer for median motor reinnervation (5,7).
RESULTS
The technique for restoration of UN motor function by transfer of the distal anterior interosseous nerve has
been well described (1,3,4,6,8). The results of the procedure have been reported in detail in Chapter 22.
The transfer of MCN branch of brachialis to the anterior interosseous nerve is a less commonly performed
procedure, and reported clinical results are limited (5,7). Gu et al. first described this procedure in 2004 and
reported the results in a single patient with preoperative M0 function in her finger flexors who regained M2
strength for FPL, M3 for FDS 1 to 3, and M2 for FDP 1 to 3 at 1 year (9). The patient had no loss of elbow
strength from her preoperative level and maintained her preoperative FCR M3 to M4 strength. The
advantages of this procedure over contralateral C7 or innervated free muscle transfer are in ease of the
procedure with a single incision exposure, ability to achieve primary neurorrhaphy without tension, and
minimal donor morbidity. A subsequent study by Zheng et al. demonstrated recovery of AIN function in 5 of
6 patients (5). Finger flexion strength was measured at mean of 66% ± 3% of the unaffected side in these 5
patients. The authors did not find any deficit of elbow flexion in their patients.
The distal AIN to ulnar motor nerve transfer is widely used as both a primary procedure to reinnervate the
hand intrinsics and a supercharge method to improve outcomes from a high UN repair. Motor deficit of the
MN, however, is a more complex clinical scenario. While free functional gracilis muscle transfer is becoming
an increasingly popular solution, there is no gold standard procedure to address this problem. In cases that
have maintained upper trunk/MCN function, the BMBMCN nerve transfer may be a simple and effective
solution. More studies are required to evaluate the longterm outcomes of this procedure.
AUTHOR'S NOTE
All photographs are from the surgeon's point of view seated at the medial aspect of the arm.
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REFERENCES
1. Tung TH, Mackinnon SE: Nerve transfers: indications, techniques, and outcomes. J Hand Surg Am 35(2):
332-341, 2010.
2. Garg R, Merrell GA, Hillstrom HJ, et al.: Comparison of nerve transfers and nerve grafting for traumatic
upper plexus palsy: a systematic review and analysis. J Bone Joint Surg Am 93(9): 819-829, 2011.
3. Weber RV, MacKinnon SE: Nerve transfers in the upper extremity. J Am Soc Surg Hand 4(3): 200-213,
2004.
4. Novak CB, Mackinnon SE: Distal anterior interosseous nerve transfer to the deep motor branch of the
ulnar nerve for reconstruction of high ulnar nerve injuries. J Reconstr Microsurg 18(6): 459-464, 2002.
5. Zheng X, Hou C, Gu Y, et al.: Repair of brachial plexus lower trunk injury by transferring brachialis muscle
branch of musculocutaneous nerve: anatomic feasibility and clinical trials. Chin Med J (Engl) 121(2): 99-104,
2008. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/18272032
6. Lee SK, Wolfe SW: Nerve transfers for the upper extremity: new horizons in nerve reconstruction. J Am
Acad Orthop Surg 20(8): 506-517, 2012.
7. Bhandari PS, Deb P: Fascicular selection for nerve transfers: the role of the nerve stimulator when
restoring elbow flexion in brachial plexus injuries. J Hand Surg Am 36(12): 2002-2009, 2011.
8. Haase SC, Chung KC: Anterior interosseous nerve transfer to the motor branch of the ulnar nerve for high
ulnar nerve injuries. Ann Plast Surg 49(3): 285-290, 2002.
9. Gu, Y., Wang, H., Zhang, L., Zhang, G., Zhao, X., & Chen, L.Transfer of brachialis branch of
musculocutaneous nerve for finger flexion: anatomic study and case report. Microsurgery 24(5), 358-362,
2004.
Chapter 22
Motor Nerve Transfers for Radial and Ulnar Nerve Injuries
J. Megan M. Patterson
Andrew Yee
Susan E. Mackinnon
INDICATIONS
Peripheral nerve injuries in the upper extremity are common and often devastating injuries. Appropriate
treatment depends upon the degree of injury (Table 22-1) (1). Level IV, V, and VI degree injuries will not
recover without surgical intervention, and a variety of strategies exist for dealing with these injuries. Primary
nerve repair, or nerve grafting if a large defect is present, has historically been the procedure of choice for
these high-degree peripheral nerve injuries (2). Unfortunately, the results after primary repair of very
proximal injuries, or injuries reconstructed with long nerve grafts, are often poor because of the irreversible
loss of distal motor end plates that occurs during the long denervation period (3). Nerve transfers have the
advantage of being close to the targeted muscle, thereby minimizing time and distance to reinnervation and
maximizing the potential motor recovery.
Several important principles must be kept in mind when considering a motor nerve transfer (1,2). The donor
nerve must be near the target motor end plates to minimize the time to reinnervation. The donor nerve must
be expendable and preferably have already separated into its terminal branch to minimize the need for
internal neurolysis. The donor should be a “pure” motor nerve and be of similar cross-sectional size as the
recipient nerve. And finally, the function of the donor nerve optimally should be synergistic with its recipient
function.
Determining the appropriate candidate for nerve transfers to treat radial and ulnar nerve lesions in the
upper extremity requires a careful assessment of the patient and includes the following (3,4):
Inadequate proximal segment of the injured nerve
Inadequate time for regeneration by primary repair or nerve grafting (as seen with proximal nerve injuries,
gaps requiring the use of large nerve grafts, or delayed presentation)
Significant risk of operating at the site of injury
Distal motor nerve transfers can be performed either end to end or end to side. End-to-end nerve transfers
are indicated in proximal IV and V degree injuries when no recovery through the native nerve is expected.
The indications for end-to-side nerve transfers (SETS) are less clear. The authors commonly use end-to-
side nerve transfers in patients with proximal II and III degree ulnar nerve injuries where complete recovery
is not guaranteed or in proximal IV and V degree injuries where some recovery may occur after primary
repair (e.g., in young children), or if a Martin-Gruber is present. In a few cases, a SETS procedure has been
performed to the posterior interosseous and extensor carpi radialis brevis (ECRB) nerve with the flexor
digitorum superficialis (FDS) for II and III degree injuries.
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TABLE 22-1 Classification of Nerve Injuries and Recovery
Surgical
Degree of Injury Recovery Rate of Recovery Management
I Neurapraxia Complete Up to 12 weeks -
II Axonotmesis Partial 1″ per month +/-
III Partial 1″ per month +/-
IV Neuroma In- None None +

continuity
V Neurotmesis None None +
VI Mixed Injury (I to V) Some fascicles (II, Depends on injury (I to +

III) V)
Motor nerve transfers offer an alternative to tendon transfers in select patients. There are many tendon
transfers available to restore both radial and ulnar nerve functions, which have been proven to be
successful (5). Nerve transfers have the benefit of maintaining the original origin, insertion, and line of pull
of the denervated muscle, which has the potential to improve patients' outcome. In the case of nerve
transfers to restore radial nerve function, they also have the benefit of allowing for more fluid and
independent finger motion (6).
CONTRAINDICATIONS
Nerve transfers are contraindicated in those patients in whom another treatment method will result in a better
outcome or an equivalent outcome with less morbidity (1). In general, nerve transfers are indicated for proximal
nerve injuries. Distal nerve injuries close to the site of motor innervation should be repaired primarily or with a
nerve graft. Neurapraxic (I) or axonotmetic (II, III) injuries should be treated expectantly without surgical
intervention as recovery is to be expected. Nerve transfers are not an appropriate option for patients who have
already experienced irreversible muscle atrophy and fibrosis due to the time that has passed from their injury. In
these patients, tendon transfers are a more appropriate option. In general, tendon transfers are not time
dependent and provide “a result” with 2 to 3 months. Tendon transfers require a supple hand and a month of
immobilization. Nerve transfers are time dependent, require a week of immobilization, and can be performed on a
stiff hand. The results with nerve transfers take longer to be realized (1 year) but continue to improve even to 5
years. The end-to-end anterior interosseous nerve (AIN) to ulnar nerve transfer provides good motor recovery
and with the radial nerve transfers outstanding recovery is frequently seen. Nerve transfers for ulnar nerve injury
do not preclude subsequent additional tendon transfers; nerve transfers for radial nerve palsies do, in general,
preclude the possibility of subsequent tendon transfers.
Electrodiagnostic studies are useful in surgical planning. They can provide information on both the extent of
injury present and the status of available donor nerves. As with tendon transfers or nerve grafting, the patient
must be optimized prior to surgery. The wound bed must be stable and without infection, and the joints powered
by the transfer should have full supple passive motion or the possibility for such (1).
TECHNIQUE (VIDEOS 22-1 AND 22-2)
Position the patient supine with the upper extremity extended on a hand table.
A nonsterile pneumatic tourniquet is placed high on the upper arm.
The operating microscope is draped and available throughout the procedure.
Nerve Transfers to Restore Ulnar Motor Function

1. Decompression of Guyon's canal.
A carpal tunnel incision is made just ulnar to the thenar crease in the palm and taken across the wrist in a
zigzag fashion, extending up the forearm between the palmaris longus (PL) and the flexor carpi ulnaris
(FCU) for approximately 14 cm (Fig. 22-1).
The ulnar neurovascular bundle (UNVB) is identified proximally and traced distally.
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The tight fascial bands volar to the UNVB are released just proximal to the wrist.
Palmaris brevis is divided if present and Guyon's canal opened.
The entire UNVB is retracted ulnarly and the hook of the hamate is palpated.
The hypothenar fascia is released just ulnar to the hook of the hamate revealing the underlying ulnar motor
branch (Fig. 22-2).
The ulnar motor branch is released around the hook of the hamate to the small-finger flexor tendons.
Stimulate the ulnar motor branch to confirm absent function.
2. Identification of ulnar nerve topography and isolation of the ulnar motor branch (Fig. 22-3).
The ulnar nerve has predictable fascicular topography in the distal forearm with the motor fascicular group
lying between the two sensory fascicular groups.
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After identification of the ulnar motor branch distally, it is “visually” neurolyzed into the distal forearm. The
motor and sensory branches remain distinct, and the authors find that they can easily be followed proximally
by visual neurolysis and do not need to be formally physically separated along their entire length. There is
often a longitudinally microvessel between the sensory and motor fascicles that can aid in their visual
neurolysis, and there is a distinct “cleavage” plane between the motor and sensory fascicular groups.
The motor branch is separated from the adjacent sensory branches at about 8 to 9 cm proximal to the wrist
crease and marked with a vessel loop.
3. Identify the AIN (Fig. 22-4).
The volar flexor tendons (except for the FCU) are swept radially to expose the PQ.
The AIN is identified proximally and in the midline of the muscle.
Separate the AIN from the adjacent vessels and follow it distally to its branching point in the middle of the
PQ, dividing the overlying muscle fibers.
The AIN is transected at its branching point.
Pass the AIN toward the ulnar nerve obliquely by dividing any vessels or muscle attachments that would
otherwise impede a straight pass.
4. Coaptation.
End to end (Fig. 22-5):
The AIN is draped over to the ulnar motor branch to determine the exact location to divide the motor
branch. The motor branch is divided proximally to allow for a tension-free transfer. Remember,
“donor/distal, recipient/proximal” mantra.
The two ends are sutured using a 9-0 nylon suture and the operating microscope. Some fibrin glue can
also be used.
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End to side.
The AIN is draped over to the motor branch of the ulnar nerve and a large epineural window is made in
the epineurium of the motor fascicle at this level.
The AIN is sutured into the epineural window with a 9-0 nylon suture and the operating microscope. This
repair is, in general, a cm proximal to the wrist crease.
After placement of one suture, the wrist and fingers are brought through full range of motion to ensure there
is no tension on the transfer.
FIGURE 22-1 Position and incision for anterior interosseous to ulnar motor nerve transfer. Note that the incision
is extended proximal until the dorsal cutaneous branch of ulnar nerve can be identified.
FIGURE 22-2 Guyon's canal release with decompression of the deep motor branch by release the tendinous
leading edge of the hypothenars. N, nerve; M, muscle.
FIGURE 22-3 Identification of the recipient motor component of the ulnar motor. This fascicular motor component
is found ulnarly, while the sensory component is found radially in the forearm. The motor component dives deep
and radially as it becomes the deep motor branch of the ulnar nerve. N, nerve; M, muscle.
FIGURE 22-4 Identification of the AIN. This donor nerve is the PQ branch of the AIN, which is found as the PQ is
divided. N, nerve; M, muscle.
FIGURE 22-5 Anterior interosseous to ulnar motor nerve transfer. The donor nerve is divided distally and the
recipient nerve proximally in order for a tension-free repair. N, nerve; M, muscle.
Nerve Transfers to Restore Radial Motor Function

1. Superficial dissection
Lazy S incision made in the proximal volar forearm beginning at the antecubital crease and extending
distally halfway down the forearm (Fig. 22-6).
Branches of the lateral antebrachial cutaneous nerve protected.
Lacertus fibrosus and volar fascia divided.
2. Exposure of the median nerve (Fig. 22-7)
Brachioradialis (BR) retracted radially and radial vessels retracted ulnarly to expose the tendon of the
superficial head of the pronator teres (PT).
Step-lengthening of superficial head of PT performed and PT retracted ulnarward.
The deep head of the PT and the tendinous arch of FDS are divided.
Median nerve identified proximally in the incision adjacent to the flexor pronator muscle.
3. Identification of branches of the median nerve (Fig. 22-8)
No intrafascicular dissection of the median nerve is performed to identify the branches.

Branch to PT
Most proximal branch and superficial branch.

Quickly divides into 2 branches.
Branch to flexor carpi radialis (FCR) and PL
Most proximal, ulnar, and deep.

Branch to FDS
More distal and ulnar.

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There are two branches of FDS.
Identified distal to FCR and PL branches.
AIN:
Larger nerve, exits radially.
Branches are stimulated with disposable nerve stimulator.
No intrafascicular dissection of the median nerve is performed to identify all the branches.
Branch to FDS, FCR/PL are divided as distally as possible just as they enter the muscle.
4. Exposure of the radial nerve (Fig. 22-9)
The radial sensory nerve is identified deep to BR.

The sensory branch is followed proximal to identify posterior interosseous nerve (PIN) and the branch to
ECRB located parallel to and radial to the sensory branch.
The vessels of the leash of Henry will have to be divided as the dissection is carried proximally to expose
the PIN.
The branches to PIN and ECRB are divided as proximally as possible above the elbow crease.
The PIN is followed distally, and the leading edge of the supinator is released to prevent compression and
allow for mobilization.
5. Coaptation without tension (Fig. 22-10)
Synergistic motor transfers are selected to facilitate motor reeducation.
FDS branch of median nerve to radial nerve branch to ECRB.
FCR/PL branch of median nerve to PIN.
Coaptation done with 9-0 nylon suture and the operating room microscope and some fibrin glue.
FIGURE 22-6 Position and incision for median to radial nerve transfers. This incision has been extended distally
in order to accommodate the PT to ECRB tendon transfer.
FIGURE 22-7 Identifying the PT tendon for an adequate proximal median nerve exposure. This tendon can either
be step lengthened or elevated for the tendon transfer for wrist extension. N, nerve; M, muscle.
FIGURE 22-8 Exposure of the median nerve and donor nerve branches. Following release of the deep head of
PT and the arch of flexor digitorum superficialis, the median nerve and its branches are identified. The donor
nerves include branches to the (1) PL/FCR and (2) FDS. N, nerve; M, muscle.
FIGURE 22-9 Exposure of the radial nerve and recipient branches. Following release of the ECRB and supinator
tendinous leading edges, the radial nerve and its branches are identified. The recipient nerves include the (1)
PIN with the supinator branch excluded and (2) the ECRB. N, nerve; M, muscle.
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FIGURE 22-10 Median to radial nerve transfers. The two transfers include (1) the PL/FCR to PIN and (2) the
flexor digitorum superficialis to ECRB. An optional sensory transfer can be performed and in this case included
the superficial branch of radial nerve end-to-side transfer to the sensory component of median nerve. N, nerve;
M, muscle.
PEARLS AND PITFALLS

The transfers must be performed without any tension. The authors find it useful to repeat the mantra
“donor/distal, recipient/proximal” prior to transecting the nerves for transfer. In general, we leave an “overlap”
between the distal and proximal transection sites of 6 to 7 cm.
Radial nerve transfers:
A simultaneous PT to ECRB tendon transfer may be done at the same time as the motor nerve transfers to
provide immediate wrist extensor power (4,7).
The branch to the supinator is excluded from the repair. This allows for better mobilization and the maximal
number of regenerating axons to be directed to wrist and finger extension.
POSTOPERATIVE MANAGEMENT FOR BOTH ULNAR AND RADIAL

TRANSFERS
The patient is placed into a long arm splint with the wrist in neutral and the elbow at 90 degrees for 2 to 3
days.
After the postoperative dressing is removed, the arm is placed into a sling for comfort and gentle range of
motion of the elbow, wrist, and hand is begun.
A wrist splint is worn to hold the wrist in neutral for 2 weeks postoperatively and is taken off for gentle range of
motion exercises for the ulnar nerve transfers.
Unrestricted elbow motion is allowed at 7 to 10 days postoperatively for the radial nerve transfers.
Strengthening and motor reeducation is begun at 4 weeks postoperatively. Exercises are focused on recruiting
the donor nerve. A skilled therapist is critical in guiding postoperative therapy.
AIN to ulnar transfer—focus on pronation.

Median to radial nerve transfer—focus on wrist and finger flexion.
COMPLICATIONS
There is always a concern about donor morbidity with nerve transfer, both in downgrading the function of
the donor muscle group and injury to adjacent branches of the main donor nerve, though this has not been
shown to be a problem clinically (2,8,9).
RESULTS
The results after AIN to ulnar motor nerve transfer have been reported in 8 patients by Novak and
Mackinnon (8). All patients showed reinnervation of the ulnar intrinsics with an approximate sixfold increase
in lateral pinch strength and grip strength. Only one patient required a secondary tendon transfer, and there
were no functional deficits related to pronation strength. Battiston and Lanzetta reported similar results in 7
patients with an average age of 32 years with high ulnar nerve injuries who were treated with distal motor
and sensory transfers from the median nerve (9). At an average of 2.5 years after surgery, 5 of these
patients had good result, one 11-year-old patient had an excellent result, and only one was reported to
have a poor result. None of these patients reported
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weakness in pronation. These results are in comparison to the uniformly poor results seen after primary
repair of high ulnar nerve injuries in adults (10,11).
Nerve transfers to restore radial nerve function have shown similar results. In 2002, Lowe et al. reported on
two patients who underwent median to radial nerve transfers with excellent recovery of wrist extension and
good recovery of finger extension at 14 months postoperatively (12). Numerous authors have further
substantiated these findings. Ray and Mackinnon reported on 19 patients who underwent nerve transfer
from the median to the radial nerve (7). They found that 18 patients had good to excellent recovery of wrist
extension and 12 had good to excellent recovery of finger and thumb extension at a minimum of 12 months
after surgery. Garcia-Lopez et al. described results after median to radial nerve transfers in 6 patients (6). At
20 months after surgery, they reported that all 6 patients showed good wrist and thumb extension, and 4 of
the 6 patients showed good finger extension. No patients suffered from loss of pronation or wrist flexion
strength. Good to excellent results are often seen after primary repair of distal radial nerve injuries, likely
related to the close proximity of the motor end plates (13). However, the same cannot be said for proximal
injuries or those requiring nerve grafting where the results are less predictable, and it is in these situations
that the authors believe nerve transfers are often indicated (13,14).
It should be noted that while the indications for nerve transfers seem to be expanding as our knowledge of
the internal topography of the peripheral nerves increases, there is still an important role for tendon
transfers, nerve grafts, and nerve repair. It is important for any surgeon operating on the peripheral nerves
to have a complete arsenal of options available in order to make the correct treatment decision for each
patient.
REFERENCES
1. Mackinnon SE, Colbert SH: Nerve transfers in the hand and upper extremity surgery. Tech Hand Up
Extrem Surg 12(1): 20-33, 2008.
2. Mackinnon SE, Novak CB: Nerve transfers—new options for reconstruction following nerve injury. Hand
Clin 15(4): 643-666, 1999.
3. Tung TH, Mackinnon SE: Nerve transfers: Indications, techniques, and outcomes. J Hand Surg Am 35:
332-341, 2010.
4. Brown JM, Mackinnon SE: Nerve transfers in the forearm and hand. Hand Clin 24: 319-340, 2008.
5. Richards RR: Tendon transfers for failed nerve reconstruction. Clin Plast Surg 30: 223-245, 2003.
6. Garcia-Lopez A, Navarro R, Martinez F, et al.: Nerve transfers from branches to the flexor carpi radialis
and pronator teres to reconstruct the radial nerve. J Hand Surg Am 39(1): 50-56, 2014.
7. Ray WZ, Mackinnon SE: Clinical outcomes following median to radial nerve transfers. J Hand Surg Am
36(A): 201-208, 2011.
8. Novak CB, Mackinnon SE: Distal anterior interosseous nerve transfer to the deep motor branch of the
ulnar nerve for reconstruction of high ulnar nerve injuries. J Reconstr Microsurg 18: 459-464, 2002.
9. Battiston B, Lanzetta M: Reconstruction of high ulnar nerve lesions by distal double median to ulnar nerve
transfer. J Hand Surg Am 24(6): 1185-1191, 1999.
10. Gaul SJ: Intrinsic motor recovery—a long-term study of ulnar nerve repair. J Hand Surg Am 7(5): 502-
508, 1982.
11. Roganovic Z: Missile-caused ulnar nerve injuries: outcomes of 128 repairs. Neurosurgery 59: 621-633,
2002.
12. Lowe JB, Tung TR, Mackinnon SE: New surgical options for radial nerve paralysis. Plast Reconstr Surg
110(3): 836-843.
13. Pan CH, Chuang DC, Rodriquez-Lorenzo A: Outcomes of nerve reconstruction for radial nerve injuries
based on the level of injury in 244 operative cases. J Hand Surg Eur 35(5): 385-391, 2010.
14. Nunley JA, Saies AD, Sandow MJ, et al.: Results of inter-fascicular nerve grafting for radial nerve lesions.
Microsurgery 17(3): 431-437, 1996.
Chapter 23
Small Joint Arthrodesis of the Hand
W. Lee Richardson
Warren C. Hammert
INDICATIONS
Arthrodesis of the small joints in the hand can be useful for a variety of conditions. Although arthritis is the
most common indication, irreparable tendon loss from trauma, reconstruction after tumor resection,
contractures, and some neurologic conditions can be treated with arthrodesis, preserving function of the
hand (1,2).
Small joint arthrodesis of either the proximal interphalangeal (PIP) or distal interphalangeal (DIP) joints
(interphalangeal joint of thumb—IP joint) is most commonly performed for arthritis (osteoarthritis,
posttraumatic arthritis, and occasionally rheumatoid or other inflammatory arthritides). Pain and stiffness
associated with these arthritides are common indications for arthrodesis. In addition, joint deformity in the
coronal plane may interfere with function, and contractures in nonfunctional positions can be problematic. In
the thumb, the metacarpophalangeal (MCP) joint can be fused and provide good outcomes with minimal
loss of function, assuming there is good function of the IP and trapeziometacarpal joints. Arthrodesis of the
MCP joints of the fingers can be more limiting and thus, arthroplasty is often preferred (2).
There are multiple fixation techniques for arthrodesis in the hand including K-wire and tension band,
intramedullary screws, and plate and screws. Overall, comparable results can be achieved using any of
these fixation techniques. Ultimately, surgeon comfort with a particular technique should guide the surgical
decision (3,4,5,6,7,8).
CONTRAINDICATIONS
Infection or poor soft-tissue coverage may be contraindications for arthrodesis. Every attempt should be
undertaken to eradicate infectious organisms and provide adequate soft-tissue coverage prior to surgery.
Shortening of the digit during the arthrodesis can improve the soft-tissue coverage. Additionally, the patient must
be able to comply with the postoperative program to ensure healing of the arthrodesis site.
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Orthogonal x-rays should determine the presence of arthritis in the joint and potential joint deforming entities
such as cystic change or bone loss.
If intramedullary screw fixation is considered, the intramedullary size should be evaluated prior to surgery as
differences will often dictate screw diameter.
Specific lab workup (e.g., rheumatoid factor, ANA, uric acid) and rheumatology consultation for suspected
inflammatory or erosive arthritides can be ordered at this time if desired but may not change surgical tactic
(9,10).
Proposed angles of fusion for specific joints are as follows:
DIP joints fused in 0 to 10 degrees flexion

PIP joints fused in 40, 45, 50, and 55 degrees of flexion from index through small finger
MCP joints fused at 25, 30, 35, and 40 degrees of flexion from index through small finger
Thumb IP joint 0 to 10 and MCP 10 to 30 degrees of flexion
TECHNIQUE
General Approach
For the DIP joint, a midline incision or H-incision is normally employed with release of the terminal extensor
tendon over the joint. Care is taken to avoid the germinal matrix when preparing the distal phalanx. The
tendon is repaired during closure to provide soft-tissue coverage over the joint.
The PIP joint can be approached through a dorsal curvilinear incision with release of the central slip. Upon
completion of the arthrodesis, the central slip is closed similar to the terminal extensor tendon at the DIP joint.
Excise collateral ligaments from both sides of the joint.
Expose the entire proximal and distal joint surfaces with hyperflexion of the joint.
Use a curette, rongeur, or burr to remove remaining cartilage and subchondral bone until cancellous bone is
present on both surfaces. The joint surfaces should be prepared so they create a fusion angle as noted
above. It is important that fusion surfaces correspond to each other as symmetrically as possible. This allows
for a larger contact area for more reliable fusion and may be accomplished by creating cartilage-free flat
surfaces or utilizing the cup-and-cone technique where the convex surface of the proximal joint surface
corresponds to the distal concave surface (Figs. 23-1, 23-2, 23-3 and 23-4) (11).
FIGURE 23-1 “H”-type incision drawn over DIP joint.
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FIGURE 23-2 Dissection showing terminal tendon over DIP joint.
FIGURE 23-3 DIP joint once collateral ligaments are released and terminal tendon incised.
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FIGURE 23-4 Prepared surfaces of DIP joint.
K-Wire and Tension Band (12)

A small hole may be placed in the proximal metaphysis of the distal bone; drill or K-wire may be used to make
your transverse hole (Table 23-1), making sure to drill parallel to the joint surface in the dorsal half of the bone
(Table 23-1).
Place double-ended K-wires from prepared joint surface out to diaphyseal region of the proximal bone.
Reduce the joint and complete K-wire fixation by advancing them into the distal bone until they contact the
distal bone surface. The fusion surface should be compressed by an assistant while the K-wires are
advanced, and rotation should be confirmed before the second K-wire is advanced into place.
K-wires should be bent and positioned to accept the tension band wire.
Create a figure-of-eight tension band, which can have either one or two twist points. Use caution as it is very
easy to break the tension wire while twisting. Alternate tightening the wire twists to get even tension in the
wire.
Bury prominent ends of tension band wire and K-wires (Figs. 23-5, 23-6 and 23-7).
TABLE 23-1 Sizing Guide
Wire Size (Gauge) Suture Drill (mm) K-Wire (in/mm)
20 #5 1.5 0.054
22 #4 1.1 0.045
24 #2 1.1 0.045
25 #1 1.0 0.035
26 #0 1.0 0.035
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FIGURE 23-5 K-wires have been passed into the proximal phalanx so the ends are at the level of the cancellous
bone.
FIGURE 23-6 Final tension has been applied with K-wires advanced across fusion site.
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FIGURE 23-7 A,B: Postoperative views of tension band construct.
Screw Fixation (13-15)

Approach in same manner as above for joint preparation.
Once adequate exposure is attained, the condyles of the proximal bone are removed, with a saw, a rongeur,
or a round burr.
Every effort is made to create a bone cut perpendicular to the longitudinal axis of the middle phalanx with a
large surface area of cancellous bone.
Dissection around the proximal aspect of the distal bone is carefully performed while protecting the skin, the
volar structures, and nail matrix when preparing the surface of the distal phalanx.
When a bony deficit is encountered, it may be easier to contour the opposite bone to match the deficit.
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For DIP joint fusion, place a guide wire antegrade in the appropriate location, usually center of the proximal
end of the distal phalanx and exiting slightly dorsal (just volar to the nail).
The double-ended wire is then advanced retrograde after the prepared joint is reduced.
When using a K-wire driver, it is important to always stabilize the distal bony structures with the contralateral
hand to avoid accidental twisting of the distal phalanx.
Appropriate screw length is determined and a cannulated drill is passed over the guide wire.
The screw is placed under fluoroscopic guidance to evaluate joint compression.
For thumb MCP joint fusion, the K-wire is advanced through the metacarpal, exiting dorsally several cm from
the joint surface. The position of the K-wire will determine the angle of the fusion. Once adequate position is
obtained, reduce the proximal phalanx to the metacarpal and advance the wire across the site of arthrodesis.
Place a second antirotational wire and measure for the appropriate length of the screw.
Use the cannulated drill over the initial K-wire until the appropriate length is prepared and place the screw,
using fluoroscopy to confirm appropriate position (Figs. 23-8 and 23-9).
FIGURE 23-8 A,B: DIP fusion using compression screw technique.
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FIGURE 23-9 A,B: MCP fusion of thumb using compression screw technique.
Plate Fixation
A more extensive approach is necessary to allow for plate fixation; the approach may be dorsal for the DIP,
PIP, and MCP joints; a lateral approach to the DIP has also been described (6).
Compression over the joint is achieved with first securing the plate to the distal segment of the joint and then
eccentrically drilling proximal screw holes that allow compression over the fusion surface.
The plate should be contoured to the appropriate fusion angle with a slight amount of overcontouring, which
will allow for more compression at the fusion site.
Rotation and angle of fusion should be verified before screw fixation is complete.
Two screws in each bone segment is adequate in our experience; however, three may also be used if fixation
is in question (Figs. 23-10 and 23-11).
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FIGURE 23-10 A-C: Unstable and painful thumb MCP joint.
FIGURE 23-11 A-C: Fusion of unstable MCP joint with plate technique.
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FIGURE 23-11 (Continued )
PEARLS AND PITFALLS

Adequate joint visualization to properly prepare joint surfaces is needed.
Do not injure the germinal matrix when preparing the distal phalanx.
Resect the minimum amount of bone necessary to expose the cancellous bone at the joint unless shortening is
desired for soft-tissue coverage.
Verify alignment and rotation and adjust as necessary before final pin placement.
Early motion in adjacent joints is essential to hand function.
Most fused MCP joints are placed in splints because of potentially high lateral stresses that may occur at this
joint. Depending on the method of fixation, PIP and DIP joints may be splinted initially for initial soft-tissue
healing, but it is imperative that patients begin motion at adjacent segments to maintain joint motion.
COMPLICATIONS
As noted by Stern and Fulton previously, nonunion, infection, painful or prominent hardware, loosening,
dorsal skin necrosis, adjacent joint stiffness, and paresthesias may occur with DIP joint fusion (16).
RESULTS
Radiographic healing of the arthrodesis site should be confirmed prior to allowing unrestricted activities.
Time to union is dependent on a variety of factors, including specific joint fused, fixation technique, and
patient factors, such as smoking (3). Leibovic and Strickland reported nonunion rates highest with crossed
K-wire fixation, and lowest with Herbert screw placement. Tension band wire fixation was intermediate.
Fusion with a tension band technique in the PIP joint may take up to 12 weeks on average to fuse and
sometimes longer (5,7).
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REFERENCES
1. Büchler U, Aiken MA: Arthrodesis of the proximal interphalangeal joint by solid bone grafting and plate
fixation in extensive injuries to the dorsal aspect of the finger. J Hand Surg Am 13(4): 589-594, 1988.
2. Burton RI, Margles SW, Lunseth PA: Small-joint arthrodesis in the hand. J Hand Surg Am 11(5): 678-682,
1996.
3. Brutus JP, Palmer AK, Mosher JF, et al.: Use of a headless compressive screw for distal interphalangeal
joint arthrodesis in digits: clinical outcome and review of complications. J Hand Surg Am 31(1): 85-89, 2006.
4. Ijsselstein CB, Van Egmond DB, Hovius SER, et al.: Results of small-joint arthrodesis: comparison of
Kirschner wire fixation with tension band wire technique. J Hand Surg Am 17(5): 952-956, 1992.
5. Leibovic SJ, Strickland JW: Arthrodesis of the proximal interphalangeal joint of the finger: comparison of
the use of the Herbert screw with other fixation methods. J Hand Surg Am 19(2): 181-188, 1994.
6. Mantovani, G, Fukushima WY, Cho AB, et al.: Alternative to the distal interphalangeal joint arthrodesis:
lateral approach and plate fixation. J Hand Surg Am 33(1): 31-34, 2008.
7. Uhl RL, Schneider LH: Tension band arthrodesis of finger joints: a retrospective review of 76 consecutive
cases. J Hand Surg 17A: 518-522, 1992.
8. Villani F, Uribe-Echevarria B, Vaienti L. Distal interphalangeal joint arthrodesis for degenerative

osteoarthritis with compression screw: results in 102 digits. J Hand Surg Am 37(7): 1330-1334, 2012.
9. Jacobs BJ, Verbruggen, G, Kaufmann RA: Proximal interphalangeal joint arthritis. J Hand Surg Am 35(12):
2107-2116, 2010.
10. Kaufmann RA, Lögters TT, Verbruggen G, et al.: Osteoarthritis of the distal interphalangeal joint. J Hand
Surg Am 35(12): 2117-2125, 2010.
11. Ahmed HA, Shaikh N, Goldie BS: Small joint fusion of the hand—a technique using Coughlin cup and
cone reamers. J Hand Surg Br 28(6): 590-592, 2003.
12. Kovach JC, Werner FW, Palmer AK, et al.: Biomechanical analysis of internal fixation techniques for
proximal interphalangeal joint arthrodesis. J Hand Surg Am 11(4): 562-566, 1986.
13. Rehak DC: Arthrodesis of the distal interphalangeal joint using a headless screw. Operative Tech Orthop
17(2): 140-147, 2007.
14. Wyrsch B, Dawson J, Aufranc S, et al.: Distal interphalangeal joint arthrodesis comparing tension band
wire and Herbert screw: a biomechanical and dimensional analysis. J Hand Surg Am 21(3): 438-443, 1996.
15. Mader K, Gausepohl T, Wolfgarten B, et al. Percutaneous arthrodesis of small joints in the hand. A
minimum three-year follow-up. J Bone Joint Surg Br 85(7): 1016-1018, 2003.
16. Stern PJ, Fulton DB: Distal interphalangeal joint arthrodesis: an analysis of complications. J Hand Surg
Am 17A: 1139-1145, 1992.
Chapter 24
Proximal Interphalangeal Arthroplasty
Xavier C. Simcock
Peter J. Evans

The proximal interphalangeal (PIP) joint is the third most common site of the osteoarthritis in the hand (1).
Although historically the gold standard for pain relief and stability for arthritic PIP joints has been arthrodesis, PIP
arthroplasty is also indicated in specific patients. The initial long-term outcomes of PIP arthroplasty were marred
by complications including loosening, fracture, instability, and frequent revision surgery (2,3,4). Advancements in
implant design and patient selection have led to more durable outcomes in PIP arthroplasty.
The overriding goal is to create a stable implant that recreates a painless flexible joint while maintaining the
function of the digit. PIP joint arthroplasty is primarily considered for patients with arthritis in the long, ring, and
small fingers. In the index finger, arthrodesis of this joint is typically considered, but bicondylar resurfacing
arthroplasty will maintain pinch strength and lateral stability, and we use this frequently.
Indications
Painful PIP arthritis secondary to osteoarthritis or posttraumatic arthritis that is unresponsive to
nonsurgical management
Silicone implants are acceptable for PIP arthritis secondary to inflammatory arthritis and some
osteoarthritis patients, and surface replacement arthroplasty (SRA) is acceptable in select “dry”
inflammatory arthritis and most osteoarthritis patients.
Relative Contraindications
Painless stiff PIP joint
Severe erosive deformity with coronal angulation greater than 30 degrees
Contraindications
Inadequate bone stock
Central slip deficiency
Previous infection
Appropriate management of PIP arthritis begins with thorough assessment of the patient. It is essential to confirm
with the patient that the primary goal of surgical intervention is pain relief and secondarily to maintain and
occasionally increase the range of motion at the joint. Patients should
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be informed that recent long-term investigations with pyrolytic carbon resurfacing implants have shown that initial
increases in range of motion are not always maintained after 5 years (2).
On exam, it is important to assess the competency of the collateral ligaments, the extensor mechanism, and to
establish any fixed contractures at the joint. Visual inspection of the alignment of the digit, as well as standard
hand radiographs, can help evaluate the degree of asymmetric degeneration at the joint.
Any evidence of an arthritic mallet deformity of greater than 15 degrees should be addressed surgically at the
time of surgery with an arthrodesis. It is our experience that these mallet deformities progress and lead to swan-
neck deformities of the finger.
SURGERY IMPLANTS
Two category types of PIP joint implants are presently available for arthroplasty: one-piece silicone and two-
piece SRA constructed from either PyroCarbon or metal and plastic. All implants offer consistent pain relief
postoperatively. The debate over implant selection revolves around long-term durability and postoperative range
of motion. Silicone has the longest history of implantation with its original description by Swanson in 1966 (5).
The long-term implant stability and wear for more demanding patients is often questioned, but even today,
silicone implants are used more frequently (6). PyroCarbon implants have been available since 2000 and are
constructed of a graphite core coated with pure carbon. This surface is advocated because of the potential for
sclerotic bone ongrowth and good wear characteristics. Recent longer-term follow-up has questioned the rates of
stability of the implant and range of motion after 5 years (2). Metal and polyethylene 2-piece bicondylar surface
implants are frequently used implants for PIP arthroplasty. Advocates for these implants praise the implant
stability and postoperative range of motion; however, one longer-term follow-up utilizing a more difficult volar
approach showed similar results as PyroCarbon implants (7). Overall, all implants can provide excellent pain
relief, but reproducible increases in postoperative range of motion remain elusive in published series. However,
our personal experience has been very favorable for two-piece metal-on-plastic implants, and they remain our
implant of choice except in “wet” inflammatory arthritis (3,4).
SURGICAL APPROACHES
Higher rates of revision surgery from PIP arthroplasty have been blamed on the initial approach, and even
among experts, controversy exists regarding the ideal surgical approach (8). Four techniques have been widely
investigated and described, each with its own reported benefits: Chamay, dorsal tendon splitting, volar, and
lateral approaches. The benefit of the Chamay technique is that it respects the extensor mechanism, but it has
been criticized for not providing access to 50% of the proximal phalanx head, as well consistently developing an
extensor lag postoperatively (9). The dorsal tendon-splitting approach was originally described by Swanson, and
the benefit of this approach is that it spares the volar plate, collateral ligaments, and dissection of the
neurovascular bundles. This approach will be described in detail in the next section, with a specific surgical and
particularly therapy modification to avoid significant extensor lag. The volar approach has recently been
repopularized and minimizes risk to the extensor complex and allows early postoperative motion (7). It is criticized
for difficulty in making accurate bony cuts, the potential of postoperative flexor tendon bowstringing, PIP
hyperextension, and violating the volar plate and collaterals, which may affect maximum stability. This approach
remains our choice for Silastic replacement as bony cuts are simpler, implants are one piece, and collateral
stability is not required. The lateral approach advocates a better recovery by avoiding both dorsal and volar
postoperative complications, but we find that for resurfacing implants, it makes rebalancing the joint difficult (10).
SURGICAL PROCEDURE (RESURFACING IMPLANTS)

In the senior author's opinion, the most consistent outcomes after PIP resurfacing arthroplasty have been with a
dorsal tendon-splitting approach and the volar approach for Silastic arthroplasty. With the PIP joint in gentle
flexion, a curvilinear skin incision is made over the PIP joint. The extensor tendon is split longitudinally and
developed as a sleeve with care taken to not violate the subtendinous fat layer proximally in order to retain
gliding postoperatively.
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Different from a tradition approach, the insertion of extensor mechanism is released at the base of the middle
phalanx (Fig. 24-1). This allows for excellent access to the joint, and upon closure, it allows for better
readjustment of the extensor insertion to accommodate the new center of rotation. To allow full exposure, the
superficial portions of the true collateral ligaments are released from the origin and insertion. In addition,
debridement of the osteophytes around the origin of the collateral ligaments and the dorsal surface of the
proximal and middle phalanx is performed. We have found that there is no need to retain or repair the collateral
ligament integrity for Silastic implants. Furthermore, with resurfacing implants, especially more challenging ones
with greater coronal angulation, release of the true collateral ligaments completely (and retention of the
accessory collateral ligaments if possible) is required to realign the joint. Importantly, if one collateral ligament is
completely released then the other should be completely released to allow balancing and avoid pivoting on one
intact ligament. In these tough resurfacing cases, we do not repair the collaterals and have had no instability
issues owing to the bicondylar nature of the metal-on-plastic implant design and more importantly our modified
postoperative protocol.
In order to create an accurate bone resection of the proximal phalanx, assess the joint for asymmetric wear of the
condyles, and make the cut with a sagittal saw at 90 degrees to the long axis of the middle phalanx. This step
can also be aided by reviewing preoperative radiographs. Scoring the dorsal surface before completing the cut
can help double-check the appropriate conservative resection, which typically just removes a thin wafer from the
intercondylar notch (Fig. 24-2). Following resection, the finger should fully extend, and under gentle traction, the
gap created should equal the thickness of the base plate thickness of the middle phalanx metal trial. Next,
especially in stiff arthritic fingers, strip the volar capsule off the posterior condyles with a Freer elevator.
Begin broaching by using the canal finder at the junction of the upper and middle two-thirds of the cut surface of
the proximal phalanx. Each implant will have their own unique features but
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general guidelines can be made. Align the broach with the long axis of the phalanx, and increase the size of the
broaches until resistance is met. Gentle malleting can help seat the broach. In addition, a blunt-tipped Swanson
burr can be used to address the impinging cortical regions allowing for the maximal size of the implant (Fig. 24-
3). Patience when broaching is essential with osteoarthritic bone compared to rheumatoid bone. The opening
and isthmus of the canal are the likely points of constriction.
FIGURE 24-1 Release of the extensor mechanism at base of P2.

FIGURE 24-2 First cut—proximal phalanx. Less is more.
After broaching, the sagittal saw is again used for the chamfer cut. Waiting to complete the chamfer cut
diminishes the chance of iatrogenic fracture while broaching by maintaining an intact volar cortex. The trial can
be inserted and can give a visual reference for the appropriate bone resection of the chamfer cut (Fig. 24-4). A
fine-tip rongeur can help ensure the trial seats perfectly. After inserting the trial on the proximal phalanx, the joint
can be put through a range of motion to assess the overall bone resection and soft-tissue balance. Full and easy
extension should be possible.
To address the base of the middle phalanx, the joint is hyperflexed and translated dorsally releasing just enough
soft tissue to allow full exposure. Both collateral ligaments are protected, and a Freer elevator can be used on
the volar cortex as a shoehorn to help gain access. The resection of bone is approximately equivalent to the
thickness of the base plate of the metal trial. The middle phalanx is broached in a similar manner to the proximal
phalanx, utilizing the Swanson burr judiciously.
In order to trial the joint, the distal implant is placed first, and then the PIP joint is hyperflexed allowing access to
impact the proximal implant. The tension is then assessed. Usually, the trials have more friction than the final
implant, but full extension should be achieved without any additional manual dorsal pressure. Collateral ligament
balance is assessed by varus/valgus stress and taking note if the distal implant will rotationally pivot on a tighter
collateral ligament. If asymmetric, we
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balance this by releasing more of the tighter collateral from its origin. Even complete release of the collaterals will
scar back up quickly, and stability is assured due to the postoperative regimen of keeping the joints in full
extension in the postoperative splint.
FIGURE 24-3 Swanson blunt-tipped side-cutting burr.

FIGURE 24-4 Chamfer cut. A: Visually approximately 45 degrees. B: Using newer intramedullary cut guides.
Prior to impacting the final implants, the extensor mechanism integrity is assessed. Currently, tendon split is
closed side to side with inverted mattress 3-0 braided nonabsorbable simple sutures, allowing the central tendon
insertion to settle proximal-distal where it is balanced with the finger in full extension as it will be postoperatively.
If there are significant concerns about extensor lag, then the central tendon is repaired using bone tunnels to the
base of the proximal phalanx. This must be determined prior to implantation by drilling 2 holes through the dorsal
cortex of the base of the middle phalanx with a Kirschner wire. A 3-0 nonabsorbable suture is then passed
through the drill holes with the needle maintained on the stitch. The final implants are impacted (Fig. 24-5). The
extensor mechanism is repaired in extension to the central tendon, which may sometimes become very
overtightened causing hyperextension if care is not taken, but a slight overtightening can aid in the prevention of
a lag. The remainder of the extensor mechanism is subsequently repaired with as above (Fig. 24-6).
FIGURE 24-5 If extensor tendon tenuous, closure with a suture through bone around the implant stem.
FIGURE 24-6 Both bone tunnel and simple side-to-side repair require secure, interrupted sutures.
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More recently, we have favored cementing all resurfacing implants, only using a small amount of cement at its
late stage of setup, rolled into a ball and hand pressurized to restrict the amount from projecting beyond the tip of
the implant.
SURGICAL PROCEDURE (SILASTIC IMPLANTS)

The volar approach is conducted via a Bruner incision over the PIP joint. The neurovascular bundles are
identified and protected with retractors throughout the dissection. The A4 and parts of the C1 and C2 pulleys are
incised in a Z-plasty fashion. The flexor tendons are retracted, and the volar plate is raised as a trap door with
the proximal insertion preserved. The collateral ligaments are detached from the proximal phalanx origin. The
joint is then hyperextended to expose the articular surfaces.
Different from the dorsal approach resurfacing implants, bone resections remove an amount of bone equal to the
size of the hinge length of the Silastic implant, removing more from the proximal versus the distal side of the joint,
and the proximal and middle phalanges are broached to trial the appropriate-sized implants. When trialing the
implant, it is critical to achieve full extension and flexion without resistance, which would indicate joint
overstuffing. If it is overstuffed, typically more bone off the proximal side will resolve this problem. The volar plate
and tendons are reduced and the skin closed.
The initial postoperative splint is in the position of function with the PIP joints at zero degrees of extension, and
patients initiate hand therapy between 5 and 7 days. A resting finger splint is constructed in full PIP extension,
often a meshed thermoplastic clamshell type. After 2 weeks postoperatively, patients are instructed to remove
the splint several times daily to conduct gradual active motion exercises to only 30 degrees of flexion, but if
unable to fully actively extend completely, this is discontinued and they remain in full extension for another week.
After 4 weeks, the splint is weaned off during the day but continued at night for an additional 8 weeks. Splint
weaning and strengthening proceed in an orderly manner based on consistent progression in active motion
(Table 24-1). An oval-8 splint is often given to prevent hyperextension, which could lead to a swanneck
deformity, and a ranger splint can be constructed for patients with a simultaneous DIP fusion (case example Figs.
24-7 and 24-8; Fig. 24-9).
TABLE 24-1 Postoperative Protocol
OT Goals 0-2 2-4 4-6 6 Weeks to 3 3 to 6

Weeks Weeks Weeks Months Months
0°
Progressive AROM & PROM to

30°
Wean Daytime Splint only,

Continue AROM
Wean Nighttime Splint
Strengthening
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FIGURE 24-7 Pre- and postoperative x-rays.
FIGURE 24-8 Postoperatively. From weeks 1 to 6 with a coaptation splint, transitioning at 6 weeks to an oval-8
splint to prevent hyperextension.
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FIGURE 24-9 Ranger splint for patients with simultaneous distal interphalangeal joint (DIP) arthrodesis and to
prevent swan neck. Simultaneously blocks DIP and extension blocks PIP.
PEARLS AND PITFALLS

With a central tendon split, the extensor mechanism insertion at the base of the proximal phalanx is released in
order to gain full visualization of the joint.
Assess for asymmetric wear of the condyles to ensure a balanced bone resection.
Always be conservative on first cut.
Complete the chamfer cut after broaching the proximal phalanx canal to minimize the stress risers during
broaching.
Patience when broaching and use of a Swanson burr are essential with osteoarthritic bone compared to
rheumatoid.
When broaching, the opening and isthmus of the canal are the likely points of constriction. Prior to impacting
the final implants, determine the need to pass the nonabsorbable suture through the bone for extensor
mechanism repair.
REFERENCES
1. Dahaghin S, Bierma-Zeinstra SM, Ginai AZ, et al.: Prevalence and pattern of radiographic hand
osteoarthritis and association with pain and disability (the Rotterdam study). Ann Rheum Dis 64: 682-687,
2005.
2. Sweets TM, Stern PJ: Pyrolytic carbon resurfacing arthroplasty for osteoarthritis of the proximal
interphalangeal joint of the finger. J Bone Joint Surg Am 93(15): 1417-1425, 2011.
3. Adams J, Ryall C, Pandyan A, et al.: Proximal interphalangeal joint replacement in patients with arthritis of
the hand: a meta-analysis. J Bone Joint Surg Br 94(10): 1305-1312, 2012.
4. Chan K, Ayeni O, McKnight L, et al.: Pyrocarbon versus silicone proximal interphalangeal joint
arthroplasty: a systematic review. Plast Reconstr Surg 131(1): 114-124, 2013.
5. Swanson AB: Flexible implant arthroplasty for arthritic finger joints: rationale, technique and results of
treatment. J Bone Joint Surg 54A: 435-455, 1972.
6. Proubasta IR, Lamas CG, Natera L, et al.: Silicone proximal interphalangeal for primary osteoarthritis using
a volar approach. J Hand Surg Am 39(6): 1075-1081, 2014.
7. Stoecklein HH, Garg R, Wolfe SW: Surface replacement arthroplasty of the proximal interphalangeal joint
using a volar approach: case series. J Hand Surg Am 36(6): 1015-1021, 2011.
8. Pritsch T, Rizzo M: Reoperations following proximal interphalangeal joint nonconstrained arthroplasties. J

Hand Surg Am 36(9): 1460-1466, 2011.
9. Wei DH, Strauch RJ: Dorsal surgical approaches to the proximal interphalangeal joint: a comparative
anatomic study. J Hand Surg Am 39(6): 1082-1087, 2014.
10. Segalman KA: Lateral approach to proximal interphalangeal joint implant arthroplasty. J Hand Surg Am
32(6): 905-908, 2007.
Chapter 25
Implant Options for the Metacarpophalangeal Joint
Gregory A. Lamaris
Mark F. Hendrickson
INTRODUCTION
Progressive destruction of the metacarpophalangeal (MP) joint can be the source of significant pain, difficulty
with performance of daily activities, and aesthetic deformity in the hand (1,2). Although in the majority of cases
MP joint arthritis is a manifestation of rheumatoid arthritis (RA), other pathologic processes such as osteoarthritis
(OA) as well as traumatic arthritis can also lead to MP joint destruction (1,2,3). MP joint arthroplasty aims at
addressing all sequelae of progressive arthritis by restoring joint range of motion, alleviating pain, and correcting
joint deformities (2,3). The MP joint plays a critical role in the function of the hand and the rest of the upper
extremity, making its repair necessary when mobility is limited by arthrosis (3). At the same time, the complexity of
the joint balancing the action of intrinsic and extrinsic muscles of the hand and offering motion in three different
planes has proven designing the perfect implant prosthesis to be a very difficult task (3,4,5). The Swanson
silicone implant first designed half a century ago still remains the point of reference for all MP implants attesting
to the challenges involved in MP implant arthroplasty (4,5).
RA and the complications from it remain the most common cause of MP joint arthritis requiring joint implant
arthroplasty (6). Affecting approximately 1.3 million people in the United States, RA is the most common cause of
arthritis following OA (1,2,4,5,6). The disease process almost routinely affects the MP joint producing typical
deformities that directly affect hand function and produce significant disability (6). Patients with RA will present
with pain, edema, and limited range of motion at the MP joint (1). The disease process typically leads to
progressive ulnar deviation and volar subluxation of the proximal phalanx with subsequent destruction of the
articular surfaces at the MP joint (4,6). Rheumatic synovitis produces several anatomic changes that contribute
to the typical ulnar deviation of the fingers: carpal collapse leading to radial deviation of the carpus, weakening of
the MP radial sagittal band causing ulnar subluxation of the extensor mechanism, damage to the accessory
collateral ligaments and volar plate causing volar and ulnar displacement of the flexor tendon sheath, and
interosseous muscle contractures creating a volar-directed force to the MP joint (4).
RA treatment is primarily nonoperative and involves splinting of the affected joints, antirheumatic medications,
and corticosteroid injections (1). First-generation disease-modifying antirheumatic medications such as
corticosteroids, methotrexate, and azathioprine have been recently replaced by drugs targeting interleukin-1 and
TNF-a (1,6). Despite the recent advances in the pharmacologic treatment for RA and the efficacy of new-
generation drugs in delaying disease progression, the vast majority of patients affected will eventually develop
worsening hand function rendering up to 13% of them completely disabled 10 years after diagnosis (6,7).
Despite the proven effects of MP joint arthroplasty in alleviating pain and significantly improving hand function in
patients with
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debilitating arthritis, there is no consensus between hand surgeons and rheumatologists regarding the
appropriate indications and timing of surgery (6,8). Of note, in a recent nationwide study, only 34% of
rheumatologists supported that MP arthroplasty improves hand function in patients with advanced rheumatoid
MP arthritis as opposed to 82.5% of hand surgeons who participated in the study (8).
Although not as common as RA, OA of the MP joint also represents a common cause of MP arthritis (1,9). Either
idiopathic or as a result of repetitive joint trauma, OA usually affects the MP joints of the index and long finger
(9). Patients present with pain and range-of-motion limitation in the affected joints, while radiographic imaging
confirms the diagnosis, demonstrating joint space narrowing, subchondral sclerosis, and formation of
osteophytes (9). Similarly to RA, nonoperative management is the mainstay of treatment for OA, to include oral or
topical nonsteroidal anti-inflammatory medications as well as corticosteroid injections (1,9). Besides
pharmacologic treatment, static and dynamic splinting plays an important role in OA treatment as it has been
proven to improve range of motion, strength, as well as dexterity in the affected joints (1). Surgical options are
reserved for patients who fail nonoperative management and include joint debridement, arthrodesis, and
arthroplasty, which is typically less complicated compared to arthroplasty in RA patients as the ligamentous
structures supporting the joint are largely unaffected by the disease process (3).
Although the thumb MP joint is more a uniaxial hinge joint, the finger MP joints are a complex condylar-type joint
allowing motion in three different planes: flexion-extension, abductionadduction, and circumduction (1,4,5). The
articular surfaces of the metacarpal head and proximal phalanx base are unique in their shape and articulation,
which, in combination with the supporting collateral ligaments and volar plate, give the joint its range-of-motion
properties (4,5). The metacarpal head is asymmetric in both coronal and sagittal planes (4), while the radial
condyle is larger in size than the ulnar one on the coronal plane resulting in the ulnar deviation of the phalanx
upon flexion, which is more pronounced in the index and middle finger, thus helping in hand grasp (4).
Furthermore, both the radial and ulnar condyles of the metacarpal head are broader in the volar surface, creating
a cam effect tightening the collateral ligaments upon MP joint flexion (4,5). As a result, joint flexion decreases the
ability of longitudinal rotation, while in maximal flexion, the MP joint behaves more as a hinge joint (4,5). In
contrast, in the extended position, the collateral ligaments are not taut, allowing for abduction-adduction and
rotation (5). The radial collateral ligament runs a more oblique course compared to its ulnar counterpart allowing
ultimately for increased ulnar deviation of the proximal phalanx during flexion and supination of the MP joint (4,5).
The aforementioned characteristics of the MP joint make the design and production of an implant for MP
arthroplasty both an engineering challenge and a manufacturing challenge. Besides the restoration of the normal
range of motion, which is complex in the case of the MP joint, the ideal implant must also provide adequate joint
stability through optimal mechanical interaction between articular contours and dynamic support of the muscles
and tendons investing the joint (5). In the MP joint, the articular surface structure, volar plate, capsule, and
ligaments play a significant role in joint stability and function; release of the collateral ligaments at the time of
native joint excision will result on ulnar bowstringing of the flexor tendons, resulting eventually in flexion
contracture and ulnar deviation of the fingers (1,5,7,10,11). Another challenge for implant-bone interface is the
fixation or setting of the device to native bone construct. The ideal implant would ensure immediate fixation of the
stems to the endosteal surface of the medullary canals upon placement, which would later be further reinforced
by bone ingrowth (2,5). The different sizes and contours or medullary canals between different metacarpals and
less so the proximal phalanges make it difficult to design a single-implant device model with stems ensuring a
perfect fit for all joints. Also, the fine structure of metacarpals and phalanges and the relative large fill volume of
these small joint implants limit these small jointimplant interfaces to withstand the high mechanical stresses.
Larger joint bone-implant material interfaces demonstrate a more optimal implant-bone interaction (5). Along the
same lines, in order to accommodate differences in hand size between patients as well as different fingers and
joint laterality, an implant solution should be produced with several models available ensuring optimal fit, making
development and production even harder to be marketable for manufacturing companies (5).
Since their first employment in the 1950s, available prostheses for MP joint arthroplasty have significantly
evolved. The available MP joint replacement systems can be divided in four different categories; hinge joint
replacements, flexible one-piece joint replacements, the newly developed surface replacement joint implants, and
the absorbable interposition implants (12,13,14). Hinged joint prostheses were the first MP joint implants to be
developed (5). Although initially simple, singleaxis metal prostheses, they subsequently developed into
metaloplastic designs consisting of a metal element articulating with a polyethylene bearing (1,2,5). Hinged joint
implants were plagued with a nonanatomic center of rotation as well as a high coefficient of friction at the hinge
mechanism (2,3,5,13). Bone resorption resulting in finger shortening and subsequent loss of range of motion,
prosthetic loosening, and implant material failure were the most common complications associated with hinged
joints and the reason they fell out of favor among hand surgeons (1,2,5,15). Flexible single-piece MP joint
implants led the next step in evolution of implant arthroplasty (2,3,5).
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Although initially designed as composite implants with a combination of silicone and other materials, the silicone
implant designed by Swanson was the one that became the implant of choice for several decades and remains
to date the point of reference for all other implants (1,2,3,5). Finally, the development of newer materials and the
application of concepts initially developed for and applied to large joint arthroplasty led to the design of surface
replacement MP joint implants, based on the articulation of the metacarpal head and proximal phalanx base with
the interposition of wearresistant materials in an effort to replicate normal MP joint mechanics and function
(2,13).
FLEXIBLE, ONE-PIECE JOINT REPLACEMENT SYSTEMS: SILICONE MP

JOINT IMPLANTS (FIG. 25-1)
Single-piece silicone implants were first described by Swanson as a treatment option for the management of
patients with arthritis involving the MP joint (16). The Swanson implant, essentially a silicone spacer for the MP
joint, was designed to correct the alignment of the MP joint but most importantly to provide joint stability and
promote the formation of a fibrous capsule around the MP joint (5,17,18). Since its introduction, the Swanson
implant has been extensively used in MP joints affected by RA as well as OA making it the most widely used and
studied implant for MP joint arthroplasty (1,4,5,17,18,19). Initially, the implant was manufactured from
conventional silicone elastomer. This material was subsequently replaced by high-performance elastomer in
order to decrease the incidence of material failure (19,20). This improved silicone material, Flexspan, is used up
to this day (19). Additionally, in an effort to delay or even completely prevent implant fractures, metal grommets
were introduced to the design of the original Swanson implant, protecting the prosthesis from damage by the
bone at the points of insertion in the medullary canals (19). Of note, implant fracture does not necessarily mean
loss of joint function, especially if encapsulation of the prosthesis has already occurred (18,19). Functionally,
Swanson implant arthroplasty shifts the arc of motion across the MP joint to a more extended position, resisting
flexion as well as ulnar deviation at the level of the MP joint (17,18,19). This functional benefit though comes with
the drawback of compromised active MP joint flexion, affecting mostly the function of the ring and small finger
(17).
In an effort to improve functional outcomes of single-piece silicone MP joint implant arthroplasty, newer implant
designs were developed. The Sutter (Avanta) implant was first introduced in the late 1980s, featuring a center of
flexion located volar to its longitudinal axis, as well as sharp, angled borders between the stems and hinge area,
differentiating it from the Swanson implant (Fig. 25-1) (21). Despite the initial enthusiasm with its use, computer
modeling later calculated higher mechanical
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stresses developing across the Sutter implant, which could account for the increased rate of implant fracture
rates observed when compared to the Swanson one, although the use of the Sutter implant resulted in greater
improvement in range of motion (21,22). Newer designs in the options for MP joint arthroplasty included the
introduction of preflexed implants, as the NeuFlex implant. The NeuFlex silicone implant, first introduced in 1998,
featured an “anatomically neutral” preformed 30% angle—simulating the relaxed position of the hand—as well as
a hinged design. The singlepiece NeuFlex implant better duplicates the anatomic center of MP joint flexion and
better mimics the resting semiflexed MP joint position, resulting in decreased mechanical stress (18,19). When
compared to the Swanson implant postoperatively, the NeuFlex implant has demonstrated a greater MP joint
range of motion and increased longevity (17,18,19). Despite minor differences in the silicone polymer used or the
implant design, silicone implants are by far the most commonly used implants in MP joint arthroplasty improving
function, decreasing pain, and correcting the appearance of the hand (19,23). Although selectively used in cases
of OA as well as traumatic arthritis of the MP joint, the main indication for the use of silicone MP joint implants is
RA (1,2,3,4,23). Patients with advanced RA, where ligamentous and soft-tissue support to the MP joint is
severely compromised as a result of the disease process, are better candidates for silicone implant arthroplasty
as opposed to younger, more active patients with either earlier-stage disease or greater functional demands from
their hands (1,2,3,4,19).
FIGURE 25-1 A: The Swanson (Wright) silicone implant. In this picture, the model depicted bears titanium
grommets protecting the implant from damage by the bone at the points of insertion in the medullary canals. B:
Silicone-based single-piece, flexible MP joint interposition implants and lateral view. NeuFlex (top), Sutter/Avanta
(middle), and Swanson (bottom).
Indications
Patients with OA who have failed a 3- to 6-month course of nonsurgical intervention, with pain and
substantial loss of function of the hand due to MP joint arthritis (1)
Patients with RA with MP significant joint deformity, destruction, or subluxation that is noncorrectable by
soft-tissue reconstruction alone (4)
Specific indications for RA patients are (4)
Arc of motion less than 40 degrees at the MP joint
MP joint displacement or flexion contracture hindering function
MP joint pain associated with radiographic abnormalities
Ulnar drift greater than 30 degrees
Contraindications (4,24)
Active or chronic MP joint area infection
Compromised local perfusion, including local vasculitis
Poor quality skin and soft-tissue coverage
Young patients (less than 50 years old) with adequate MP joint functional range of motion (60 to 70 degrees)
Unsatisfactory appearance without MP joint functional loss
Insufficient bone stock or inadequate intramedullary bone volume
Thorough physical examination with documentation of observed skin; extrinsic and intrinsic muscle tendon
position and function; wrist and hand bone/joint findings including every MP joint functional range of motion
(affected and unaffected on each side).
Standard AP, oblique, and lateral plain films to assess the bone quality and volume and to facilitate implant
sizing.
Especially in RA patients: nutritional assessment; organ system comorbidities; antirheumatic medications;
infection presence and risk; cervical spinal stability (1).
Patients with RA significantly affecting the distal radial ulnar joint and wrist joint should be addressed prior to
undergoing MP joint arthroplasty and rehabilitation. Persistent supination/radial deviation of the carpus will
cause recurrent MP ulnar drift postoperatively.
Surgical Technique (Fig. 25-2) (4,9,25-30)

The procedure can be performed on a regular hand table under tourniquet using either general or regional
anesthesia. After administration of perioperative antibiotics and sterile surgical field prep and draping, the
procedure commences with exsanguination of the extremity with an Esmarch elastic bandage. Then, either a
dorsal longitudinal incision is made over the single MP joint or dorsal transverse (at metacarpal neck level) if
more than one MP joints are to be replaced (4,25,27). After exposure of the extensor mechanism, the MP joint is
approached through one of several paths, directed by the anticipated surgical goals: the central extensor
complex is divided longitudinally;
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or if more optimal, the ulnar sagittal band is incised longitudinally to allow mobilization of the extensor complex in
a radial direction (most typically to correct extensor subluxation) (26,28) or, alternatively, an incision along the
radial sagittal band to allow mobilization of the extensor complex in an ulnar direction (25,27). A longitudinal
incision is placed over the joint capsule, and following synovectomy or capsulectomy as needed, the metacarpal
head is exposed first. The collateral
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ligaments are subperiosteally freed as well as the intrinsic muscle tendons including the abductor digiti quinti
(4,25,27). The MJ joint is exposed and explored by maximally flexing and exposing the metacarpal head. The
metacarpal neck is then transected perpendicular to its longitudinal axis just distal to the origin of the collateral
ligaments with an oscillating saw (4). Most authors advocate preserving the radial collateral ligament at the time
of bone resection if possible (9). Specifically in the case of RA patients with ulnar deviation, the displacement
can be corrected by release of the ulnar collateral ligament and tightening of the joint capsule and radial
collateral ligament (25,27). Furthermore, in order to assist correction and limit recurrence of ulnar drift, some
authors release and transfer or cross over the ulnar intrinsic tendon/lateral band to the adjacent finger radial
collateral ligament/radial intrinsic tendon/lateral band area: index to long, long to ring, and ring to small finger
(29). In nonrheumatoid MP joint arthritis, optimal metacarpal length, joint stability, and joint range of motion are
maintained in part by minimal metacarpal resection distal to the collateral ligament attachments and by volar
metacarpal head oblique resection (30).
FIGURE 25-2 Silicone implant MP joint arthroplasty. Following joint exposure, the metacarpal is transected
perpendicular to its longitudinal axis just distal to the origin of the collateral ligaments, and the proximal phalanx
articular cartilage is excised (A). After broaching both medullary canals and selection of the appropriate size
implant, the final implant is inserted in the metacarpal bone first and then in the proximal phalanx with flexion and
distraction at the MP joint (B,C). Following placement of all implants (D), the radial collateral ligament is then
secured to the metacarpal with the previously placed suture, and the dorsal hood is repaired by imbricating or
reefing the radial sagittal band to centralize the extensor tendon as needed (E). The skin is closed with
interrupted nylon sutures over a drain (F).
The medullary canal of the metacarpal is then reamed and sequentially broached to fit an appropriately sized
prosthesis. The articular cartilage at the base of the proximal phalanx is then excised, and the medullary canal is
similarly broached (4). The trial implant is then inserted and the joint reduced to assess appropriate sizing and
soft-tissue balance. The transverse midportion of the implant should rest against both bone cut surfaces, while
the prosthesis should have a snug fit in both canals without being compressed during joint extension (do not
overstuff). Before the final prosthesis is inserted, two small drill holes are made on the dorsoradial aspect of the
metacarpal neck, and a 4-0 nonabsorbable braided suture is passed through in preparation for reconstruction of
the radial collateral ligament if that has not been preserved at the time of bone resection. Bony canals are at that
point irrigated in preparation for implantation, and the edges of bone in contact with the implant are smoothed
with a rasp. The final implant is inserted in the metacarpal canal first and then with flexion and distraction at the
MP joint into the proximal phalanx canal (4). The radial collateral ligament is then secured to the metacarpal with
the previously placed suture, and the dorsal hood is repaired by imbricating or reefing the radial sagittal band to
centralize the extensor tendon (4,9,25,27).
In more significant MP dislocation more proximal metacarpal bone cuts are required. Furthermore, the volar plate
must be released proximally and the radial 2/3 resected leaving the radial 1/3 to reattach to the radial aspect of
the metacarpal to correct palmar subluxation and ulnar deviation. Additionally, the ulnar intrinsic insertion to the
ulnar volar plate insertion on the proximal phalanx should be released allowing for rebalancing and prevention of
overstuffing and subluxation.
A cross intrinsic transfer can be performed at this point, if desired. The skin is closed with interrupted nylon
sutures, over a drain if needed (4). A bulky dressing is applied and volar splint with the wrist supported in slight
extension, the MCP joints near or full extension, the fingers supported in slight radial deviation, and the PIP joints
in slight flexion.
Pearls and Pitfalls

Preserving superficial veins in the dorsal surface of the hand will help decrease postoperative digital edema
(4).
When performing MP implant arthroplasty in the small-finger MP joint, it is recommended to preserve the flexor
digiti quinti brevis muscle, or flexion in the finger will be compromised postoperatively (4).
Consider not releasing the ulnar intrinsic muscles to the index finger, in order to preserve function of the first
palmar interosseous muscle in pinch grip (4).
When reaming the medullary canal of the proximal phalanx, orientation should be such to minimize the
rheumatoid deformity. The proximal phalanx of the index finger should be reamed at a supinated position to
prevent pronation deformity and allow better tip pinch, while the small-finger canal is reamed in slight
pronation to improve grip (4).
Use a nontouch technique upon placement of the implant with smooth forceps as even minor surface defects
can propagate and result in implant fracture (4).
Postoperative Care
If present, the drain is removed on postoperative day 1. Dressings are removed 2 to 3 days after the operation,
and gentle active range-of-motion exercises are started 3 to 7 days after the operation (4,9). For the first 6
weeks, digits are maintained in neutral position or slight radial deviation with a dynamic extension splint and a
night static extension resting splint in order to protect the soft-tissue reconstruction, control alignment, and
maintain range of motion (4,9). The dynamic splint is removed after 4 to 6 weeks and the patients start on a
strengthening program, while the night-resting splint can be maintained for 3 to 4 months (4,9). Although some
authors support the addition of continuous passive motion regimen for the MP joints after implant arthroplasty as
part of
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the postoperative course, this has not been proven to ultimately result in increased range of motion or grip
strength (31).
Complications
Wound infection and subsequent implant infection requiring debridement, antimicrobial treatment, and
implant removal.
Inaccurate sizing resulting in poorly fitting implant that compromises postoperative functional outcome
and increases early implant failure risk (too small causing instability and bony impingement and too large
causing limited extension).
Failure to restore soft-tissue supporting structures appropriately can result in joint instability, tendon
subluxation, and ulnar deviation postoperatively.
Results
Despite the ongoing debate regarding specific indications and timing for MP joint arthroplasty, silicone MP
joint implants have been proven to be a reliable option in the armamentarium of the hand surgeon for the
treatment of debilitating arthritis (1,2,6). Since the introduction of the Swanson implant more than 40 years
ago and the subsequent introduction of newer silicone implants, several published studies have assessed
their efficacy in addressing pain associated with MP joint arthritis, improving hand function (1,2), and also
correcting hand appearance, which is a strong motivator for patients seeking operative intervention (32).
Silicone MP joint implants are still the most widely used implant by hand surgeons, while the Swanson
implant specifically remains the benchmark against which all other MP joint reconstruction options have to
be compared (1,2,6). Newer designs of silicone implants have been developed over the past several years
in an effort to decrease the incidence of implant fracture associated with the Swanson implant and improve
functional outcomes although their superiority has yet to be proven (19).
MP joint changes associated with advanced RA remain the most common indication for MP joint
arthroplasty (1,2,19). Patients with advanced RA where soft tissue and ligaments supporting the MP joint
are severely affected by the disease process make the ideal candidates for silicone implant arthroplasty as
silicone implants function more as a dynamic spacer for the MP joint until their encapsulation, not relying on
soft-tissue support (19). Silicone implant arthroplasty has been proven to be highly effective in correcting
ulnar drift as well as quality of life in patients with RA, although it has been shown to offer small
improvement in range of motion and grip strength (6,33). In a recently published multicenter prospective
outcomes study, patients with RA treated with silicone arthroplasty achieved significantly higher Michigan
Hand Questionnaire (MHQ) scores when compared to controls 3 years after the procedure (34). The
longevity of the Swanson silicone implant was demonstrated in a retrospective study assessing the
survivorship of silicone implant arthroplasty in the long term. When using revision arthroplasty as the
endpoint for the analysis, the Swanson implant had an 83% 10-year survival, which decreased to 63% at
the 17-year mark, while the incidence of revision for implant fracture was only 3% (35). Of note, in this
study, the overall incidence of implant fracture was 42% and 66% at 10 and 17 years postoperatively, which
underscores the fact that implant fracture does not necessitate revision arthroplasty if encapsulation of the
implant has already occurred (18,19,35).
Several studies have assessed differences in implant survival as well as functional outcomes between the
different types of silicone implants used for MP joint arthroplasty in patients with RA. In a prospective
randomized trial comparing the Swanson to the Sutter implant, no significant differences were found
between the study groups with regard to range of motion as well as correction of ulnar deviation and pinch
strength (25). Similar results were reported from another prospective randomized study comparing the two
implants, although the fracture rate for the Sutter implant was higher when compared to that of the Swanson
implant at 2-year follow-up (20% vs. 13%, respectively) (21). Furthermore, the use of the Sutter implant was
associated with a higher incidence of osteolysis of the metacarpal bone and the proximal phalanx when
compared to the Swanson implant and has led to a redesigned implant (36). The more recent NeuFlex
design silicone implant has been found to significantly increase patient occupational performance score
when compared to the Sutter implant 1 year postoperatively (37). When compared to the Swanson implant,
two prospective randomized controlled trials have demonstrated that the NeuFlex implant significantly
increases the active MP joint flexion and arc of motion while it achieves comparable results when it comes
to active MP joint extension, correction of ulnar drift, and composite flexion (17,18). Of note, both the
Swanson group and the NeuFlex group had similar functional outcomes on objective joint function tests,
while patients treated with the Swanson implant showed better self-reported function and aesthetic outcome
on MHQ scoring (17).
Besides their well-documented results in patients with RA in need of MP joint arthroplasty, silicone implants
have also been used in patients suffering from nonrheumatic MP joint arthritis (5,9,30). As mentioned
earlier, patients with age-related, traumatic, or idiopathic OA differ significantly
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from patients with RA as MP joint arthritis is not part of a systemic disease and they do not have the wrist,
MP, and interphalangeal joint deformities seen in RA affecting the tendons and soft tissue supporting the
joint (9). In the first case series reported in the literature, silicone arthroplasty resulted in significant patient-
reported improvement in hand function and pain relief (9). Furthermore, silicone implant arthroplasty
significantly improved MP joint flexion and half the patients were found to have an increase in the joint arc
of motion (9). Those results were confirmed by a more recent retrospective study assessing silicone
arthroplasty in patients with noninflammatory MP joint arthritis that demonstrated statistically significant
improvement in patient-reported Disability of the Arm, Shoulder, and Hand (DASH) score; pain; as well as
significant increase in range of motion following arthroplasty, without any changes noted in grip or pinch
strength (30). Besides the traditional design Swanson and Sutter silicone implants, the newer, “anatomically
neutral” NeuFlex implants have also been shown to achieve good results in patients with noninflammatory
MP joint arthritis (38).
In summary, single-piece silicone implants represent the most widely used material for MP joint arthroplasty
in both rheumatic and nonrheumatic arthritides (1,2). Over the long-standing history of their use, silicone
implants have been proven to achieve significant pain relief, improve hand aesthetics, and offer patient
satisfaction (1,2,6). Furthermore, the Swanson implant has the added advantage of clinical experience
compared with many other MP arthroplasty options supporting its use (1,2,19). Despite good results in
treatment of MP joint arthritis, the use of silicone implants does not come without drawbacks, as rates for
implant fracture, subsidence, and recurrent hand deformity are high in the long term (28), while their use
has also been associated with development of more serious complications such as silicone synovitis,
lymphadenopathy, and even malignant lymphoma (39). Especially in the case of patients with advanced RA,
silicone implants constitute an appealing option as their function principle relies on implant encapsulation
with limited requirements for soft-tissue joint support (1,2,3,6,19). In contrast, patients at earlier stages of
the disease and patients with noninflammatory OA represent a different population with higher functional
demands in the long term following arthroplasty. These patients typically have a soft-tissue envelope that
can provide more support to the implanted device, which led to the development of unconstrained
arthroplasty designs (40).
UNCONSTRAINED, SURFACE REPLACEMENT JOINT REPLACEMENT

SYSTEMS (FIG. 25-3)
The concept of surface replacement implant arthroplasty systems for the MP joint emerged as an evolution of
articulating joint systems (1,2,3). This led to the design of unconstrained prosthetic joints closely approximating
normal anatomy to mimic normal joint biomechanics, relying mostly on native soft-tissue support for joint stability.
Surface joint replacement systems are hence based on the articulation of the metacarpal head and proximal
phalanx base using wear-resistant materials extensively used in large joint reconstruction systems (1,2,13).
The two-piece PyroCarbon (Ascension) total joint prosthesis system is manufactured with pyrolytic carbon and is
the most extensively studied and most widely used surface replacement joint arthroplasty system for the MP joint
(2,3,19,40). Pyrolytic carbon is a synthetic material produced during pyrolysis of hydrocarbon gas, resulting in
the formation of a highly durable material with mechanical and physical properties falling between graphite and
diamond (3,41,42). For the production of the PyroCarbon joint system, the pyrolytic carbon coating is applied to a
high-strength graphite core, creating an implant with elastic modulus similar to cortical bone that is highly
compatible with living tissue and maintains optimal properties for load transfers between implant and bone
(2,3,43,44). The articulating surfaces of the PyroCarbon joint system closely resemble the surfaces of the
proximal phalanx base and the metacarpal head for increased range of motion, while the hemispheric
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articulating surfaces are supported by offset intramedullary stems to counteract ulnarly directed forces (2,3).
Furthermore, the PyroCarbon joint system is specifically designed to require minimal bone resection and
preserve the collateral ligaments (2,3). Minimal bone resection increases the contact area between trabecular
and cortical bone for load distribution, while the preserved collateral ligaments stabilize the joint, prevent
subluxation, and most importantly transmit load from the joint to the bone cortical surface instead of the
endosteal surface, thus decreasing bone-implant wear (3). During implant installation, stems are secured in
place with impaction and subsequently fixed by appositional growth, resisting longitudinal subsidence and
increasing long-term durability (3,40,45) (Fig. 25-4).
FIGURE 25-3 MP joint surface replacement implants. A: Integra PyroCarbon MP joint replacement system. B:
Avanta SR MCP joint replacement system.
FIGURE 25-4 PyroCarbon implant arthroplasty. In this case of index and long MP arthroplasty, the joints are
exposed through a longitudinal incision over the MP joint (A), and dissection is carried through the joint capsule.
The joint is flexed, and the metacarpal medullary canal is entered with the starter awl inserted in the dorsal third
of the metacarpal head (B). Appropriate canal alignment is then confirmed using an alignment awl (C), the
alignment guide is switched for the cutting guide, and the metacarpal osteotomy is performed (D).
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FIGURE 25-4 (Continued ) The proximal phalanx osteotomy is performed after the medullary canal is then
opened in a similar fashion (E). Following the proximal phalanx and metacarpal osteotomies, both medullary
canals are sequentially broached until the final broach rests 1 mm below the osteotomy level (F,G). Upon
completion of broaching, the trial implants are impacted in place until seated at the level of the osteotomies (H,I).
The trial implants are removed, final implants are inserted, and the joint is reduced and inspected for stability and
range of motion. The wound is closed in layers by repair of the joint capsule, extensor mechanism, and skin (J),
while the implant positioning is once more radiologically confirmed (K).
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Following the same principles used in the design of PyroCarbon MP joint replacement systems, several other MP
joint prostheses have become available (2,19), although the majority of them have yet to be proven successful in
long-term clinical studies. The total MP replacement system (Finsbury Orthopedics) consists of an ultra high
molecular weight polyethylene (UHMWPE) phalangeal component articulating to a hemispherical-shaped
metacarpal component made of cobalt-chrome alloy, while both components have fins for fixation in the
medullary canals (46). UHMWPE is also employed in another MP joint replacement system designed by Zimmer,
Europe, consisting of two components made of titanium where the metacarpal component has a UHMWPE
hemispherical cap articulating against a concave phalangeal component (19,47). The Moje ceramic on ceramic
finger prosthesis consisting of two components made of bioceramic-coated zirconium and the Andigo metal-on-
metal prosthesis consisting of two components manufactured with cobalt-chrome alloy share similar design
characteristic where a hemispherical metacarpal head articulates with a concave matching surface of the
phalangeal base component (19). No clinical studies have been published on the results of either of those two
MP joint arthroplasty options.
The Avanta SR MCP finger prosthesis is a newer developed MP joint surface replacement system, unique in its
minimally constrained, unlinked design (2). Similarly to the total MP replacement system, the phalangeal
component is made of UHMWP, while the metacarpal component is manufactured with a cobalt-chrome alloy.
The SR MCP design aims at replicating normal joint anatomy; the metacarpal head component is elliptically
shaped in its sagittal projection in an attempt to reproduce the normal joint-changing center of rotation, while it
also has volar flanges to increase surface contact during joint flexion and in that way augment radioulnar stability
(2). To further increase the system's stability, the proximal phalanx component has an extended dorsal lip to
prevent joint subluxation, while the metacarpal component bears a raised portion centrally to prevent ulnar drift
(2,5). Lastly, the low-profile design of both components ensures preservation of the collateral ligaments for
added joint stability. Of note, the Avanta SR prosthesis is the only one of the aforementioned systems where the
components are secured in place with use of cement (phalangeal side), which has been linked in past designs
with poor clinical results (2,5,46).
Indications
Patients with OA who have failed a 3- to 6-month course of nonsurgical intervention, with pain and
substantial loss of function of the hand due to MP joint arthritis (1)
Younger, active lifestyle patients with OA or early RA patients placing higher demands on MP joint (1,2,5)
Patients with early RA changes to include little deformity, subluxation, or dislocation and intact collateral
ligaments (48,49)
Contraindications
Active or chronic infection in the MP joint (4,24)
Presence of vasculitis or poor skin condition (4,24)
Dislocated joint with shortening of more than 1 cm (relative contraindication) (48)
Advanced cortical bone loss or inadequate intramedullary space (48)
Advance RA with soft tissue inadequate for joint stability (3,19,40,49)
Joint extension lag greater than 45 degrees and ulnar deviation greater than 30 degrees (49)
Older, incapacitated patients with limited functional demands from their hand (4,24)
Documentation of observed deformities and functional range of motion for each of the affected MP joints
(2,3,19); verification that volar subluxation or ulnar deviation deformities can be corrected at the time of
surgery (49)
Standard AP, lateral, and oblique plain films to assess bone erosion and also to template size of the implants
(48,49)
Especially in RA patients, assessment of nutritional status, comorbidities, antirheumatic medications, risk for
infection, and presence of cervical spine instability (1)
Surgical Technique (49)

Since the PyroCarbon implant is the most widely used and tested surface replacement implant, here follows a
description of the implant insertion procedure based on manufacturer's recommendations.
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For a single joint, a longitudinal incision is made of the dorsum of the MP joint. A transverse incision is made
over the MP joints when multiple joints are to be replaced. The dissection is carried through the joint capsule
to visualize the metacarpal base and proximal phalanx base.
The MP joint is flexed, and the metacarpal medullary canal is then entered initially with a K-wire or bone awl
inserted centrally in the dorsal third of the metacarpal head and then opened with the alignment awl and
guide. Appropriate canal alignment and position are then confirmed with the alignment guide and an alignment
awl in place under fluoroscopic inspection.
The alignment guide is exchanged for the cutting guide, and the metacarpal osteotomy is then performed 1 to
2 mm distal to the collateral ligament dorsal attachments making a 27.5-degree distal back cut until the saw
reaches the alignment awl. The awl and guide are removed, and the osteotomy is completed freehand
following the cutting guide-defined plane.
The proximal phalanx medullary canal is then opened in a similar fashion with a K-wire and a starter awl,
which is then replaced by the alignment awl attached to the alignment guide. The MP joint is flexed during this
process to protect the dorsal metacarpal osteotomy lip.
The alignment guide is switched to the cutting guide, and a 5-degree back cut is made 0.5 to 1.0 mm proximal
to the collateral ligament attachments.
After osteotomies are completed, medullary canal broaching starts at the distal component of the joint. The
phalangeal medullary canal is sequentially enlarged until the final broach rests 1 mm below the osteotomy
level.
The metacarpal medullary canal is broached sequentially in a similar fashion to the same size broach that was
used in the proximal phalanx medullary canal.
Upon completion of broaching, the trial implants are impacted in place until seated at the level of the
osteotomies, starting with the distal component.
The joint is then reduced and assessed for range of motion as well as presence of laxity. After trial implant
insertion, joint motion should range between full flexion and 10 to 15 degrees of hyperextension. If following
trial implant insertion, the MP joint is lax, the next larger size trial implants are impacted and ranged for fit. The
joint area is inspected for possible damage to the collateral ligaments. Collateral ligament damage is repaired,
and MP joint stability and range are reconfirmed.
The trial implants are removed, and final implants are positioned and impacted. Proper alignment between the
metacarpal and phalangeal components is critical. Correct implant alignment is ensured by confirming that the
dorsal metacarpal and phalangeal component surfaces are parallel.
The joint is reduced once more and inspected for stability and range of motion.
The wound is closed in layers by repair of the joint capsule, extensor mechanism, and skin.
A bulky dressing is applied, maintaining wrist at slight dorsiflexion and slight ulnar deviation, MP joint in full
extension, and proximal interphalangeal joints in 5 to 10 degrees flexion.
Pearls and Pitfalls

Preserving superficial veins in the dorsal surface of the hand will help decrease postoperative digital edema
(4).
Starting osteotomy should be limited to the joint's articular surface to preserve collateral ligaments; only resect
minimum bone to allow implant accommodation (40,48,49).
Before starting the saw, ensure perfect positioning by sliding the saw through the cutting guide (49).
During insertion of K-wires, awls, and broaching of either the metacarpal or phalangeal medullary canal,
ensure joint is adequately flexed to prevent impingement of the phalanx or metacarpal bone, respectively, by
instruments (49).
To correct overburring or overbroaching the medullary canal affecting implant seating, consider impaction
grafting using morcellized graft from the proximal phalanx (49).
Prevent volar subluxation or dislocation of the implant with meticulous repair of the joint capsule (40,48,49).
Postoperative care
On first postoperative visit, the original splint is taken down, and the patient is provided with a dynamic extension
assist splint maintaining the wrist at 0 to 10 degrees extension and slight ulnar deviation, the MP joints in neutral
extension with slight radial deviation, and the proximal interphalangeal joint and thumb free (49) and a resting
static splint with the wrist, MP joints, and IP joints in the noted positions. The dynamic and static splints are
interchanged for rehabilitation exercises and rest periods (40,49).
For OA patients, short arc flexion protocol for the MP joints is initiated at 3 weeks postoperatively, starting at 30
degrees and gradually increased by 10 degrees every week. The flexion block
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splint is worn at all other times for a total of 6 weeks when not using the dynamic extension splint, while it is also
used as resting splint during nighttime. At 6 weeks postoperatively, the patient is allowed to remove resting splint
for light activities. The MP flexion block daytime splinting is discontinued at 10 to 12 weeks postoperatively, while
nighttime splinting is continued as needed for 3 to 6 months (40).
Patients with RA are provided with a dynamic extension splint and a daytime flexion block splint as above, while
they use a different nighttime resting splint that holds the wrist at 0 to 10 degrees extension and slight ulnar
deviation, MP joints at 0 degrees extension with finger dividers to promote slight radial deviation, and proximal
interphalangeal joints at comfortable flexion (49). Flexion protocol exercises in the dynamic extension splint are
started at 3 weeks postoperatively, but it is imperative that the MP joint is not allowed to flex past 45 degrees for
at least 6 weeks after the surgery (49). Patients are gradually weaned off the dynamic splint as well as the MP
flexion block splint as range of motion increases to full flexion between 6 and 12 weeks postoperatively as long
as proper alignment is maintained, while the nighttime resting splint should continue to be worn for life (49).
Complications
Wound infection and subsequent implant seeding requiring implant removal
Joint instability or soft-tissue imbalance secondary to inadequate musculotendinous soft tissues resulting
in joint subluxation or dislocation requiring implant revision (48,49)
Implant fracture requiring removal or implant loosening requiring revision (48)
Inaccurate sizing and insertion of poorly fitting implant compromising postoperative functional outcome
and resulting in early implant failure
Results
Unconstrained surface replacement systems for MP joint arthroplasty were designed to closely approximate
normal joint camlike biomechanics relying significantly on soft-tissue joint envelope as well as
musculotendinous support to provide joint stability (2,3,19,40). Hence, younger patients with
noninflammatory arthritis, where the soft tissues supporting the joint are not involved in the disease
process, are ideal candidates for the procedure (2,3,19,40). In the latest published study assessing the
long-term outcome of PyroCarbon arthroplasty in patients with OA, the joint range of motion increased by an
average of 14 degrees postoperatively, while long-term survival of the implants reached 91% at an average
4 years of follow-up (40). Furthermore, almost all patients were satisfied with their outcome, and a
significant percentage of them were able to return to work without restrictions (40). In an earlier study
assessing PyroCarbon arthroplasty results in a mixed population of 61 patients with different arthritis
etiologies, patients with OA were found to have a statistically significant grip strength and oppositional pinch
at an average follow-up of 18 moths, while the recorded increase in range of motion did not reach statistical
significance (3). Interestingly, almost all patients reported complete pain relief at 1-year follow-up with the
majority of them reporting significant improvement in both appearance and functionality of the operated joint
(3). Similar results were also published in another study assessing PyroCarbon arthroplasty in patients with
OA, with a 10-degree increase in range of motion and significant pain improvement in 10 patients (50).
Joint arthroplasty in patients with RA is more complex than is that in patients with OA or other causes of
noninflammatory arthritis. As described earlier in this chapter, patients with RA can have ligamentous and
capsular incompetence resulting in decreased joint stability providing less support to surface replacement
implants (3). Despite these concerns, PyroCarbon implants have been successfully used in select patients
with MP joint arthritis secondary to RA (3,48). In one of the earlier studies assessing outcomes of
PyroCarbon arthroplasty, an average 13-degree increase in range of motion was noted, and the majority of
patients noticed significant pain improvement. Long-term implant survival was 81% at 10 years and 70% at
15 years postoperatively, while 12% of implants required revision for various etiologies such as joint
stiffness, component malpositioning, implant fracture, joint subluxation, or dislocation (48). Of note, only
patients with no or little joint deformity or subluxation were selected for PyroCarbon arthroplasty in this
study. A more recent study that included patients with preoperative joint subluxation as well as patients with
previously failed silicone arthroplasty also reported encouraging results. Specifically, range of motion
increased by 13%, with significant increase in MP joint flexion and decrease in extension lag at 1 year
postoperatively. Furthermore, the majority of patients reported significant improvement in pain along with
improved appearance and function of their hand with patient satisfaction reaching 90% 1 year after the
surgery (3).
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Although the majority of published studies on surface replacement implants report the results of PyroCarbon
arthroplasty, other surface replacements systems have also been studied with encouraging results.
Specifically, the outcome of implant arthroplasty using the total MP replacement system consisting of cobalt-
chrome-molybdenum alloy and UHMWPE components was assessed in patients with OA (46). Patients
reported almost complete resolution of joint pain at 3 and 5 years' follow-up. Furthermore, arthroplasty
improved the joint range of motion from a mean of 27 degrees preoperatively to a mean of 60 degrees at
final follow-up (46). Despite initial concerns for component loosening using this particular design given the
fixation method to the medullary canals with fins on the sides of the implant components, no changes in
implant positioning were noted at follow-up except for one patient where the metacarpal components had
settled by 2 mm, almost 7 years postoperatively (46).
In conclusion, although not as extensively studied as silicone arthroplasty, surface replacement implant
arthroplasty for the MP joint has been found to have encouraging results in patients with both rheumatic
and noninflammatory arthritides. Initial results across different studies show significant improvement in joint
pain as well as an increase in pinch and grip strength of patients with OA and RA (3,40,48,50). Although
additional long-term studies are necessary in order to better define rate of complications, implant survival,
and need for implant revisions, it is apparent that surface replacement systems hold promise as a reliable
MP implant arthroplasty option. Furthermore, surface replacement arthroplasty might not be the ideal
implant choice for all cases of MP joint arthritis. Younger patients who would place greater demands on
their implants and patients with OA where the musculotendinous units supporting the joint are mostly intact
represent the ideal candidates for surface replacement arthroplasty (19). On the contrary, sequelae of RA,
includes bone erosion and incompetence of the collateral ligaments and joint capsule, can limit the use of
surface replacement arthroplasty in this patient population unless patients are operated on earlier in the
course of the disease; in these cases, the surgeon's expertise and skill in preserving and repairing the soft-
tissue joint envelope become of critical importance for the procedure outcome.
ABSORBABLE INTERPOSITION IMPLANTS FOR THE MP JOINT

Bioabsorbable interposition implants for the MP joint represent one of the latest advancements in MP joint
arthroplasty (14,51). They were developed in an effort to achieve similar functional results to the silicone
interposition implants while at the same time avoiding common complications associated with the use of silicone
arthroplasty as silicone synovitis and peri-implant osteolysis (51). Absorbable implants are disc shaped and
consist of a biodegradable poly-L/D-lactide copolymer scaffold manufactured from knitted multifilament yarn that
is characterized by long resorption time that can reach up to 3 years following implantation (51). This scaffold
functions as a temporary spacer in the MP joint providing support and guiding soft-tissue ingrowth and ultimately
leading to the formation of flexible but durable pseudojoint (51). The implant is placed with a technique similar to
the one used for silicone arthroplasty, although no intramedullary preparation is necessary as the implants are
stemless. Briefly, the metacarpal head is resected distally to the collateral ligaments insertion, and the implant is
inserted in the joint space and secured to the metacarpal bone with absorbable sutures following which soft-
tissue balancing is performed as needed (14,51). In a recently performed prospective study comparing the
absorbable implants with silicone arthroplasty in patients with RA, similar outcomes were achieved in both
groups with regard to ulnar drift correction, improvement in power grip and functional grip measurements, and
patient satisfaction (14). However, the incidence of palmar subluxation recurrence at follow-up was significantly
higher in the absorbable implant group, making the Swanson implant a better option for patients with RA where
palmar instability is commonly encountered as part of the disease process (14).
THUMB MP JOINT ARTHROPLASTY

Arthritis of the thumb MP joint is far less common than MP joint arthritis encountered in the rest of the hand (52).
As with finger MP joints, progressive destruction of the thumb MP joint can be either the result of chronic
repetitive joint loading in heavy laborers or the result of trauma damaging the collateral ligaments and thus
affecting joint stability (52). Furthermore, RA can affect the thumb MP joint as well as the interphalangeal joint
(1,52). In contrast to finger MP joint arthritis, thumb MP arthritis failing nonoperative management is usually
treated with joint arthrodesis (52). MP joint fusion can be accomplished with several different techniques
achieving high fusion rates, while the resulting functional deficit is well compensated by the large degree of
motion at the level of the carpometacarpal joint (52). For patients who prefer motion-preserving modalities of
treatment, MP
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arthroplasty can also be employed. The Steffee implant, a two-part polyethylene and metal-hinged prosthesis, is
the implant most commonly used for thumb MP arthroplasty (52,53). In the largest study available in the literature
including a total of 54 thumbs, all patients that underwent thumb MP joint arthroplasty using the Steffee implant
reported significant pain improvement while maintaining an average range of motion of 21 degrees at the MP
joint, and implant survival after 10 years reached 89% (53). Newer developed surface replacement implants such
as the PyroCarbon have yet to be tested for thumb MP arthroplasty. In conclusion, thumb MP arthroplasty,
although an available option for carefully selected patients, does not represent at this time the standard of care.
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37. Pettersson K, Wagnsjö P, Hulin E: NeuFlex compared with Sutter prostheses: a blind, prospective,
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40. Wall LB, Stern PJ: Clinical and radiographic outcomes of metacarpophalangeal joint pyrolytic carbon
arthroplasty for osteoarthritis. J Hand Surg Am 38(3): 537-543, 2013.
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Organs 7(2): 263-269, 1979.
42. Haubold AD: On the durability of pyrolytic carbon in vivo. Med Prog Technol 20(3-4): 201-208, 1994.
43. Cook SD, Beckenbaugh RD, Redondo J, et al.: Long-term follow-up of pyrolytic carbon
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44. Cook SD, Klawitter JJ, Weinstein AM: The influence of implant elastic modulus on the stress distribution
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phalangeal joints. J Hand Surg Br 28(5): 432-438, 2003.
47. Rieker CB, Joyce T, Unsworth A, et al.: Tribologic investigation of a metacarpophalangeal prosthesis.
Orthopade 32(9): 784-788, 2003.
48. Cook SD, Beckenbaugh RD, Redondo J, et al.: Long-term follow-up of pyrolytic carbon
Metacarpophalangeal implants. J Bone Joint Surg Am 81(5): 635-648, 1999.
49. PyroCarbon MCP joint surgical technique. www.ascensionortho.com
50. Nunez CA, Citron ND: Short-term results of the Ascension pyrolytic carbon metacarpophalangeal joint
replacement arthroplasty for osteoarthritis. Chir Main 24(3-4): 161-164, 2005.
51. Honkanen PB, Kellomäki M, Konttinen YT, et al.: A midterm follow-up study of bioreconstructive
polylactide scaffold implants in metacarpophalangeal joint arthroplasty in rheumatoid arthritis patients. J
Hand Surg Eur Vol 34(2): 179-185, 2009.
52. Shin EK, Osterman AL: Treatment of thumb metacarpophalangeal and interphalangeal joint arthritis.
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53. McGovern RM, Shin AY, Beckenbaugh RD, et al.: Long-term results of cemented Steffee arthroplasty of
the thumb metacarpophalangeal joint. J Hand Surg Am 26(1): 115-122, 2001.
Chapter 26A
Moderate Arthritis: Osteotomy, Arthroscopy, and Subtotal
Trapezial Excision
Gregory A. Lamaris
Michael K. Matthew
INTRODUCTION
The carpometacarpal (CMC) joint of the thumb is the second most common site for osteoarthritis of the hand
(1,2,3). The thumb CMC joint consists of the articulation between the base of the thumb metacarpal and the
trapezium forming a biconcave-convex saddle joint, allowing the movement of the thumb metacarpal in 3 different
planes including abduction-adduction, flexion-extension, and axial rotation (4). The CMC joint along with the
trapezium-second metacarpal and scaphotrapeziotrapezoid (STT) joint is stabilized by a total of 16 ligamentous
structures, creating a tension band that prevents subluxation from cantilever forces experienced during pinch
(1,2,4). Of these numerous ligaments, failure of the anterior oblique “beak” ligament plays a significant role in the
development of CMC osteoarthritis (1,5). Laxity of the beak ligament results in uneven stress loads in the CMC
joint during pinch and grasp leading to the development of synovitis and ultimately to articular wear, cartilage
loss, and development of osteoarthritis with osteophyte formation (1,2,3,5). The thumb metacarpal base
eventually subluxates dorsally and radially resulting in adduction of the metacarpal diaphysis and compensatory
hyperextension of the first metacarpophalangeal (MP) joint (2) (Fig. 26A-1).
Patients typically present with a chief complaint of pain at the thumb base, usually exacerbated by gripping or
pinching maneuvers, without history of local trauma (2,4,6). Physical exam will reveal tenderness overlying the
CMC joint and, in more advanced stages, a positive grind test and crepitation over the joint. Differential
diagnosis includes de Quervain's tenosynovitis, tendonitis
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of the flexor carpi radialis (FCR) or the extensor carpi radialis longus and brevis, STT arthritis, and scaphoid
pathology (2,4,6). Radiologic findings confirm the diagnosis and also determine the stage of the disease process
based on 2 available classification systems, one described by Dell et al. (7) and the other by Eaton and Glickel
(8) (Table 26A-1). The Dell system uses the degree of thumb metacarpal subluxation as a staging tool, while the
Eaton system uses the changes in the joint space and the size of osteophytes forming in the joint as staging
criteria. Although the Eaton classification system offers only moderate interobserver agreement and does not
correlate with patient symptom severity, it remains the most widely used reference to guide treatment options (9).
FIGURE 26A-1 Plain film of the wrist demonstrating typical changes in advanced CMC arthritis; as disease
progresses, the thumb metacarpal base eventually subluxates dorsally and radially resulting in adduction of the
metacarpal diaphysis and compensatory hyperextension of the first MP joint.
Treatment options for the management of CMC arthritis vary greatly depending on the stage of the disease,
symptoms, level of patient functional impairment, and surgeon preference (1,2,6,10). Furthermore, the increasing
popularity of minimally invasive arthroscopic procedures as well as the development of new implant materials for
joint reconstruction have created new trends in the management algorithm (1,2,6,11). A recent review of several
studies evaluating different surgical and nonsurgical treatment strategies in patients with CMC arthritis
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concluded that patients with Eaton grade I CMC arthritis are more likely to benefit from nonoperative
interventions while the choice of treatment for patients with grade II to grade IV arthritis will depend on severity of
symptoms and functional demands with no one surgical option proven to be superior to another (12).
TABLE 26A-1 Classification of Thumb CMC Arthritis per Eaton and Glickel (8)
Stage Characteristics
I Slight joint space widening, normal articular contours, and less than one-third subluxation in
any projection
II Capsular laxity with at least one-third joint subluxation. Osteophytes less than 2 mm are
present adjacent to the volar or dorsal trapezium facets.
III Joint subluxation greater than one-third and slight joint space narrowing. Osteophytes greater
than 2 mm present
IV Advanced degenerative changes. Very narrow joint space with major subluxation and cystic
and sclerotic bone changes. Significant erosion of the dorsal-radial trapezial facet
Management of mild to moderate CMC arthritis starts with activity modification, nonsteroidal anti-inflammatory
drugs, and the use of either prefabricated or custom-made opponens splints (6,10,13). These treatment options
decrease the friction at the inflamed joint and improve but can be seen by patients as overly restrictive. Injection
of the joint with either corticosteroids or hyaluronic acid (off-label) preparations is the next available option
(1,2,6,10) and is usually met with at least temporary relief. Failure to adequately control symptoms with
nonoperative management and disease progression are indications for surgical intervention (1,2,10). Commonly
performed procedures for the management of mild to moderate CMC arthritis include the extension-abduction
osteotomy, CMC joint arthroscopy with debridement, synovectomy and possible capsulodesis, and the partial
trapeziectomy with or without interposition (1,4,6,11).
1. OSTEOTOMY
Basal abduction osteotomy of the first metacarpal for the treatment of CMC arthritis was initially described
several years ago as an alternative to more invasive procedures as total trapeziectomy or CMC joint fusion (14).
The osteotomy is designed to address the radial subluxation of the first metacarpal base and the adduction
deformity of the first metacarpal diaphysis. It was reported to restore the thumb grasp power as well as the ability
of the hand to grasp larger objects (14). The procedure entails a resection of a wedge of bone from the radial
aspect of the first metacarpal base and then abducting the distal diaphysis segment for closure of the osseous
defect (Fig. 26A-2) (14). The efficacy of the abduction osteotomy is a result of the biomechanical effect it has in
the CMC joint, transferring the force during thumb pinch and grasp to the dorsal area of the CMC joint, which is
usually less affected (15,16). The thumb is placed in a more abducted and extended position, changing the
distribution of stress to a more vertical vector across the joint, decreasing the tendency for thumb subluxation,
and thus reducing the shearing forces causing the cartilage
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degeneration (1,15). The main advantage of the procedure is the fact that it is extra-articular and therefore
preserving all other surgical options if the disease process continues to progress to more advanced stages
(1,14,15,16).
FIGURE 26A-2 Basal abduction osteotomy in the treatment of CMC arthritis. The procedure entails a resection
of a wedge of bone from the radial aspect of the first metacarpal base and then abducting the distal diaphysis
segment for closure of the osseous defect.
Indications
Eaton stage I and II CMC arthritis
Patients in whom the cartilage wear is limited to the volar surface of the joint, before complete articular
cartilage loss (1)
Younger patients and patients who might need additional procedures in the future for progression of the
disease as it preserves all joint reconstruction options (15)
Contraindications
Fixed metacarpal subluxation or CMC joint space narrowing indicating involvement of the entire joint or joint
instability making ligament reconstruction necessary (15,16,17,18)
Advanced disease with involvement of the dorsal joint surface (6)
Dynamic thumb collapse on lateral pinch that can interfere with the biomechanical benefit of the transfer of
force dorsally following the procedure (Fig. 26A-3) (18)
FIGURE 26A-3 Dynamic thumb collapse observed in advanced stages of CMC arthritis as a result of thumb
metacarpal adduction deformity and compensatory MP joint hyperextension during pinch. Unless the deformity is
corrected at the time of the surgery, it can interfere with the success of the osteotomy in transferring force during
thumb pinch and grasp to the dorsal area of the CMC joint.
Operative Technique (14,15,18)

The procedure can be performed on a regular hand table under tourniquet using either general or regional
anesthesia. After the CMC joint is localized with the use of a needle, a linear or zigzag incision is made on the
dorsal aspect of the metacarpal extending from the CMC joint distally for 4 cm. Taking special care to identify
and preserve the branches of the radial sensory nerve and protect the extensor pollicis longus (EPL) and brevis
tendons dissection proceeds circumferential to the metacarpal base in a subperiosteal plane.
A transverse osteotomy is performed with an oscillating saw 1 cm distally to the metacarpal base in a dorsal to
volar direction. Before the complete transection of the volar cortex, the saw blade is left in place as a guide, while
a second osteotomy is performed 2 to 5 mm distally. The plane of the distal osteotomy is planned so that it
intersects the plane of the proximal osteotomy at the site of the volar cortex. In that fashion, a dorsally based
wedge of bone is removed creating a 30-degree abduction of the metacarpal. After drilling transverse holes 5 to
6 mm proximally and distally to the osteotomy site, a cerclage wire is passed around the osteotomy site and is
tightened to approximate the two bone fragments. The fixation can be reinforced with a K-wire passed obliquely
across the osteotomy site. Alternatively, fixation can be accomplished with application of a mini-plate over the
osteotomy site (Fig. 26A-4). The periosteal origin of the thenar muscles is repaired, and after skin closure, a
thumb spica splint is applied.
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FIGURE 26A-4 A: Preoperative picture of CMC joint demonstrating typical changes of stage I arthritis; slight joint
space widening, normal articular contours, and less than one-third subluxation of the thumb metacarpal base. B:
Postoperative picture following metacarpal base abduction osteotomy. Osteotomy is placed 1 cm distally to the
metacarpal base to produce a 30-degree abduction. Fixation of the two bone fragments is accomplished in this
case with the use of a mini-plate over the osteotomy site.
Pearls and Pitfalls

Precisely identify the CMC joint with the use of a needle in order to appropriately position the osteotomy 1 cm
distal to the metacarpal base; start with the proximal osteotomy first making sure it is perpendicular to the
metacarpal diaphysis axis; second osteotomy should be 5 mm distally to the first one at a 30-degree angle so
that it intersects the proximal one at the volar metacarpal cortex (18).
At the end of procedure, assess joint laxity and possible need for abductor pollicis longus (APL) tendon
shortening (15).
Potential pitfalls include operator errors in technique as well as poor patient selection, resulting in persistent
symptoms (18).
At the end of the procedure and after appropriate osseous apposition is confirmed, the hand is placed in a well-
padded thumb spica splint, which is changed to a thumb spica cast when patient is seen in clinic. Cast is
removed after another 6 weeks and when plain films confirm union. Physical therapy starts at cast removal with
thumb CMC and MP progressive mobilization and strengthening (15,18).
Complications
Nonunion (14,15,18) of the osteotomy site
Loss of positioning at the osteotomy site, K-wire failure (15,18)
Infection at the K-wire pin site
Radial digital sensory nerve branch damage (14,15,18)
Persistent pain secondary to unrecognized pantrapezial disease (15,18)
Results
Despite the fact that extension osteotomy was first described several years ago, its role in the treatment of
CMC arthritis is still not well defined as there is a lack of large-scale studies objectively assessing the long-
term effects on pain relief and restoration of hand function (15,18). In the initial description of the procedure,
Wilson (14) reported complete resolution of symptoms in all cases as
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well as restoration of a powerful thumb grasp. A large published series of twelve cases reported 80%
patient satisfaction at the end of an average follow-up period of 4 years (19). In the series with the longest
follow-up published, almost all patients maintained oppositional pinch and grip that either equaled or
exceeded that of the contralateral hand (15). In the largest retrospective review including a total of 50
patients treated with osteotomy and followed for a mean time of 7 years, 82% of patients were found to
have pinch strength comparable to the contralateral arm while 80% of them reported resolution of pain (20).
The low complication risk associated with the procedure, its proven biomechanical benefits even in
advanced joint disease, and the fact that it does not interfere with future surgical interventions for joint
reconstruction make abduction osteotomy a good option for the treatment of moderate CMC arthritis
(14,15,18,19). Furthermore, with the advance of minimally invasive techniques, osteotomy has recently
been employed in combination with arthroscopy for diagnosis and treatment of CMC arthritis (21).
2. ARTHROSCOPY
Recent technologic and technical advances in the field of endoscopic surgery have made the arthroscopy of
small joints feasible and have introduced CMC joint arthroscopy as a valuable tool in both the diagnosis and the
treatment of CMC arthritis (4,6,11,21,22,23). As with other endoscopic and arthroscopic techniques, CMC
arthroscopy has the benefit of being a less invasive procedure, associated with minimal tissue trauma,
decreased recovery time, and preserving joint motion (22). First, arthroscopy offers an objective assessment of
the extent of the CMC joint involvement, allowing direct visualization of the articular surfaces and inspection of
the ligamentous integrity (21). This is of great value especially in the case of early and moderate CMC arthritis
where the radiographic findings do not always correlate with clinical symptoms making the diagnosis of
underlying disease challenging (1,2). Specifically, Badia (24) has recently suggested an alternative staging
system for CMC arthritis, based solely on arthroscopic findings (Table 26A-2). Furthermore, after accurate
assessment of the extent of CMC arthritis, arthroscopy offers several treatment options based on disease
severity. Patients with arthroscopic stage I disease where the articular cartilage is mostly intact will benefit from
joint debridement, synovectomy, and possibly thermal ligament shrinkage, while patients with more extensive
disease with cartilage loss and pronounced ligament laxity might also require more invasive procedures as
osteotomy or hemitrapeziectomy (21,23).
TABLE 26A-2 Arthroscopic Classification of Thumb CMC Arthritis per Badia (24)
Stage Arthroscopic Changes
I Intact articular cartilage and diffuse synovial hypertrophy. Disruption of the dorsal-radial
ligament and inconsistent attenuation of the anterior oblique ligament
II Intense synovial hypertrophy, disruption of the dorsal-radial ligament, and constant

attenuation of the anterior oblique ligament. Eburnation of the articular cartilage on the ulnar
third of the base of first metacarpal and central third of the distal surface of the trapezium
III Less severe synovitis but frayed volar ligaments with laxity. Widespread full-thickness loss
with or without a peripheral rim on both articular surfaces
Indications
Eaton stage I or stage II CMC arthritis, refractory to conservative nonoperative management
Active, young patients requesting to return to work as soon as possible
Contraindications
Advanced stage CMC arthritis
Pantrapezial involvement with arthritic changes in the scaphotrapezial and trapeziotrapezoid joint surfaces
Articular cartilage loss indicating the need for partial or complete trapeziectomy
Technique (4,6,23)
The procedure is performed under regional or general anesthesia, starting with assembly of the arthroscopy
tower. The thumb is attached to the tower with a finger trap, the rest of the hand and arm is adequately padded
and secured to the tower, and thumb traction is set between 5 and 10 pounds.
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Surface landmarks are marked, to include the EPL, the extensor pollicis brevis (EPB), and APL, as well as the
positions for 1-R (directly radial to the APL at the level of the CMC joint) and 1-U (directly ulnar to the EPL)
portals (4,23). Through the 1-R portal, the operator can visualize the dorsal-radial, the palmar oblique, the thumb
ulnar collateral, the intermetacarpal ligament, as well as the insertion of the anterior oblique ligament (23) (Fig.
26A-5). The 1-U portal can be used for visualization of the anterior oblique ligament (23). The tourniquet is then
inflated, and the joint is entered under fluoroscopy assistance with a small-gauge needle and distended with
injection of saline. The arthroscopy portals are then entered into the joint space, as confirmed by egression of
saline, while adequate joint distention is maintained by constant saline flow at 60 mm Hg. Diagnostic arthroscopy
ensues using a 1.5-mm, 1.9-mm, or 2.7-mm arthroscope with initially evaluation of the arthritic changes to the
joint surfaces and cartilage. Any loose bodies are removed, and a 2.9-mm or 3.5-mm full-radius shaver can be
used for debridement of all diseased cartilage and synovium. An electrothermal radiofrequency ablator can be
used to perform capsular shrinkage at this point if any ligamentous laxity is encountered, as well as
chondroplasty in cases of focal cartilage wear or fibrillation. At the conclusion of the procedure, portals are
removed and skin at the port entry is approximated with monofilament suture.
FIGURE 26A-5 CMC joint arthroscopy and partial trapeziectomy. The joint is entered under fluoroscopic
assistance and distended with injection of saline. Through the 1-R portal, the operator can visualize the thumb
metacarpal base as well as the trapezium articular surface (A). The volar oblique ligament can also be easily
identified either through the 1-R or the 1-U portal (B). After diagnostic arthroscopy, a radius shaver (C) can be
entered in the joint to diseased cartilage debridement (D) or partial trapeziectomy.
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Pearls and Pitfalls
The 1-R portal is placed between the APL and FCR tendon. The closer it is to the FCR, the better is the
triangulation and thus the visualization of the joint (23)
The 1-U portal is close to the branches of the superficial radial nerve as well as the radial artery. To decrease
chances of iatrogenic injury to these structures, only incise the skin and then bluntly dissect down to the joint
capsule using a small hemostat (23).
Upon entering the CMC joint with either a needle or trocar, maintain a distal direction of approximately 20
degrees to clear the dorsal flare of the metacarpal base and avoid iatrogenic cartilage damage (21).
Upon performing capsulorrhaphy with the radiofrequency probe, avoid thermal necrosis by performing
longitudinal strides on the lax capsule, leaving stripes of vascularity in between, also referred as the striping
technique (21).
After the completion of the procedure, skin incisions are closed and hand is placed in a well-padded short arm
thumb spica splint. Splint is removed at the 2-week post-op visit, and if arthroscopy has not been combined with
another procedure and no hardware is in place (e.g., osteotomy, trapeziectomy), active and active-assisted
range of motion exercises can then begin. Therapy advances to strengthening exercises as tolerated without any
functional restrictions (6).
Complications
Disease progression and need for additional procedures for advanced disease
Damage to radial digital sensory nerve branches at port entry sites paresthesia
Results
In the largest retrospective cohort study comparing arthroscopy, debridement, and synovectomy compared
to nonoperative management, arthroscopy was found superior as documented by increased VAS and DASH
scores at 1-year post-op follow-up and the surgically treated patients had significantly increased mean
pinch strength (11). Another recent study assessing the efficacy of arthroscopic electrothermal
capsulorrhaphy in 17 cases of CMC joint laxity documented improved pain and statistically significant
increase in pinch strength in all treated patients at 2 years of followup (25). Although there are no
randomized prospective trials comparing arthroscopy with other treatment options for early and moderate
CMC arthritis, it is gaining popularity for both diagnosis and treatment of early and moderate CMC arthritis
(4,6,21,22,23). Arthroscopic visualization of the joint space allows for accurate assessment of extent of
disease, offering the opportunity to perform the least aggressive procedure needed based on the
intraoperative findings, thus giving patients with early-stage disease less invasive alternatives (21). Besides
the advantages inherit with arthroscopic procedures offering decreased tissue trauma and faster healing
times, arthroscopy can be combined with other procedures as osteotomy, hemitrapeziectomy, or implant
arthroplasty as needed for cases where more advanced disease is encountered (4,21,22).
3. SUBTOTAL TRAPEZIAL EXCISION

In cases of more advanced damage in the CMC joint with cartilage loss, arthroplasty with excision of the
trapezium articular surface is usually indicated to alleviate symptoms (4,6). Initial treatment approaches included
complete trapeziectomy, which, although very successful treating joint pain, did not address thumb pinch
strength and stability (6). Furthermore, trapeziectomy is often paired with either synthetic spacers or tendon
interposition at the time of the original procedure to prevent loss of thumb height postoperatively (6,11,26). In an
effort to maintain the osseous foundation of the thumb, partial trapeziectomy was introduced with or without
interposition arthroplasty, especially in cases where the scaphotrapezial joint was not involved in the arthritic
process (4,6,27).
With the evolution of arthroscopic treatment of mild to moderate CMC arthritis, the combination of arthroscopic
subtotal trapeziectomy and capsulorrhaphy secured with either a K-wire or suspensionplasty has emerged as a
treatment option for patients with less severe disease, offering faster recovery times while at the same time
maintaining the options for more advanced and invasive open procedures, if disease progression continues (4).
Indications
Eaton stage I or stage II CMC arthritis, refractory to conservative nonoperative management
Active, younger patients requesting a less invasive procedure with faster recovery times
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Contraindications
Significant or symptomatic pantrapezial arthritis
Scaphotrapezial arthritis
Significant hyperextension deformity at the thumb MP joint
Technique
Procedure begins with complete arthroscopy as described earlier in this chapter. At the conclusion of the
diagnostic arthroscopy, the articular cartilage of the distal trapezial surface is initially removed with the use of a
3.5-mm radius shaver (4,6,27). Once all cartilage is removed, a full-radius 2.9-mm burr is used for the
hemitrapeziectomy, which is changed to a 3.5-mm burr once enough space has been developed in the joint (6).
Under fluoroscopic guidance, the distal half of the trapezium is removed (usually 3 to 5 mm). At the completion of
the subtotal trapeziectomy, the joint is assessed for ligamentous instability, in which case the ligamentous
capsule can be tightened with the electrothermal probe as described in the previous section. The thumb
metacarpal is then stabilized to the residual trapezium with a 0.045 Kirschner wire at a slightly abducted position
in order to prevent proximal migration (4,6).
As an alternative to K-wire fixation, the metacarpal can be secured in place using a suspensionplasty with a
suture button technique such as the Mini TightRope (Arthrex, Naples, FL) (4,28). This is performed by first
making an incision over the radial border of the first metacarpal base, volar to the APL tendon. A 1.2-mm guide
wire is passed from the first metacarpal base to the dorsal-ulnar border of the second metacarpal base, slightly
distal from the first metacarpal base insertion site. An incision is then made over the ulnar part of the second
metacarpal base to expose the guide wire and its course through all 4 cortices is overdrilled with a 2.7-mm
cannulated drill. The cannulated passer is then inserted over the guide wire and the guide wire is exchanged for
the Mini TightRope, which is passed from an ulnar to radial direction so that the oblong button exits at the first
metacarpal base. The cannulated passer is then removed and the Mini TightRope round button is then secured
at the base of the second metacarpal base. After confirming adequate suspension with fluoroscopy, the Mini
TightRope is securely tied in place.
Pearls and Pitfalls

Monitor and confirm exact portion of trapezium that is excised as well as identify any residual bone.
Alternate positions for the arthroscope and instruments as needed to obtain optimal view during trapeziectomy.
Using the R-1 portal, sweep the burr from ulnar to radial direction to contour a smooth surface (4).
Intermittently irrigate the joint space in order to prevent overheating of the burr as well as remove debris from
the working space (4).
At the end of the procedure, hand is placed in a well-padded thumb spica splint. At first postoperative visit 2
weeks after procedure, the sutures are removed and the splint is exchanged for a thermoplastic splint worn for
another 2 weeks before the K-wire is removed and range of motion exercises are started (4,6). If procedure
involved suspensionplasty with the Mini Tight rope, early range of motion therapy commences at 2 weeks
postoperatively (4,6).
Complications
Damage to radial digital sensory nerve branches
Flexor pollicis longus tendon damage secondary to thermal injury during capsulorrhaphy
Scaphotrapezial joint arthritis development
Metacarpal base dislocation, subluxation, and proximal migration resulting in persistent symptoms
Results
In one of the largest studies reported evaluating its effects in 18 cases, arthroscopic partial trapeziectomy
paired with thermal capsulorrhaphy for the management of CMC arthritis was found to have very good long-
term results (27). At an average of 7 years of follow-up, the majority of patients were found to have
unchanged grip strength and improved key pinch without any cases of metacarpal subluxation noted.
Although partial trapeziectomy was initially combined with interposition of an autograft, allograft, or
prosthetic material spacer to prevent loss of radiographic postsurgical space and metacarpal subluxation
following arthroplasty, the combination of partial trapeziectomy with thermal shrinkage of the capsular
ligament was found to have comparable results (27). Furthermore,
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despite initial concerns for the subsequent development of scaphotrapezial arthritis requiring further
surgery, retrospective studies on patients undergoing partial trapeziectomy have shown no symptomatic
progression of arthritis to the scaphotrapezial joint at 9 years of follow-up (26). Partial trapeziectomy has
been proven to be an effective option for the treatment of CMC arthritis maintaining ligamentous stability at
the scaphotrapezial joint and improving grip and pinch strength (4,6,26,27). The combination of minimal
morbidity, short recovery time, and the fact that it leaves options for future procedures open if needed
makes it a good option for the management of early to moderate CMC arthritis in younger patients
(4,6,26,27).
REFERENCES
1. Gillis J, Calder K, Williams J: Review of thumb carpometacarpal arthritis classification, treatment and
outcomes. Can J Plast Surg 19(4): 134-138, 2011.
2. Patel JT, Beredjiklian PK, Matzon JL: Trapeziometacarpal joint arthritis. Curr Rev Musculoskelet Med
6(1): 1-8, 2013.
3. Armstrong AL, Hunter JB, Davis TR: The prevalence of degenerative arthritis of the base of the thumb in
post-menopausal women. J Hand Surg Br 19(3): 340-341, 1994.
4. Abzug JM, Osterman AL: Arthroscopic hemiresection for stage II-III trapeziometacarpal osteoarthritis. Hand
Clin 27(3): 347-354, 2011.
5. Pelligrini VD: Pathomechanics of the thumb trapeziometacarpal joint. Hand Clin 17: 151-168, 2001.
6. Yao J, Park MJ: Early treatment of degenerative arthritis of the thumb carpometacarpal joint. Hand Clin
24(3): 251-261, 2008.
7. Dell PC, Brushart TM, Smith RJ: Treatment of trapeziometacarpal arthritis: results of resection
arthroplasty. J Hand Surg 3(3): 243-249, 1978.
8. Eaton RG, Glickel SZ: Trapeziometacarpal osteoarthritis: staging as a rationale for treatment. Hand Clin 3:
455-471, 1987.
9. Spaans AJ, VanLaarhoven CM, Schuurman AH, et al.: Interobserver agreement of the Eaton-Littler
classification system and treatment strategy of thumb carpometacarpal joint osteoarthritis. J Hand Surg Am
36(9): 1467-1470, 2011.
10. Wolf JM, Delaronde S: Current trends in nonoperative and operative treatment of trapeziometacarpal
osteoarthritis: a survey of US hand surgeons. J Hand Surg Am 37(1): 77-82, 2012.
11. Furia JP: Arthroscopic debridement and synovectomy for treating basal joint arthritis. Arthroscopy 26(1):
34-40, 2010.
12. Wajon A, Carr E, Edmunds I, et al.: Surgery for thumb (trapeziometacarpal joint) osteoarthritis. Cochrane
Database Syst Rev (4): CD004631, 2009.
13. Swigart CR, Eaton RG, Glickel SZ, et al.: Splinting in the treatment of arthritis of the first carpometacarpal
14. Wilson JN: Basal osteotomy of the first metacarpal in the treatment of arthritis of the carpometacarpal
joint of the thumb. Br J Surg 60(11): 854-858, 1973.
15. Parker WL, Linscheid RL, Amadio PC: Long-term outcomes of first metacarpal extension osteotomy in the
treatment of carpal-metacarpal osteoarthritis. J Hand Surg Am 33(10): 1737-1743, 2008.
16. Pellegrini VD, Parentis M, Judkins A, et al.: Extension metacarpal osteotomy in the treatment of
trapeziometacarpal osteoarthritis: a biomechanical study. J Hand Surg Am 21(1): 16-23, 1996.
17. Eaton RG, Littler JW: Ligament reconstruction for the painful thumb carpometacarpal joint. J Bone Joint
Surg Am 55(8): 1655-1666, 1973.
18. Tomaino MM: Basal osteotomy for osteoarthritis of the thumb. J Hand Surg Am 36(6): 1076-1079, 2011.
19. Futami T, Nakamura K, Shimajiri I: Osteotomy for trapeziometacarpal arthrosis. 4 (1-6) year follow-up of
12 cases. Acta Orthop Scand 63(464): 462-464, 1992.
20. Hobby IL, Lyall HA, Meggitt BF: First metacarpal osteotomy for the trapeziometacarpal osteoarthritis. J
Bone Joint Surg 80(3): 508-512, 1998.
21. Badia A, Khanchandani P: Treatment of early basal joint arthritis using a combined arthroscopic
debridement and metacarpal osteotomy. Tech Hand Up Extrem Surg 11(2): 168-173, 2007.
22. Kapoutsis DV, Dardas A, Day CS: Carpometacarpal and scaphotrapeziotrapezoid arthritis: arthroscopy,
arthroplasty, and arthrodesis. J Hand Surg Am 36(2): 354-366, 2011.
23. Adams JE, Steinmann SP, Culp RW: Bone-preserving arthroscopic options for treatment of thumb basilar
joint arthritis. Hand Clin 27(3): 355-359, 2011.
24. Badia A: Trapeziometacarpal athroscopy: a classification and treatment algorithm. Hand Clin 22(2): 153-
163, 2006.
25. Chu PJ, Lee HM, Chung LJ, et al.: Electrothermal treatment of thumb basal joint instability. Arthroscopy
25(3): 290-295, 2009.
26. Noland SS, Saber S, Endress R, et al.: The scaphotrapezial joint after partial trapeziectomy for
trapeziometacarpal joint arthritis: long term follow-up. J Hand Surg Am 37(6): 1125-1129, 2012.
27. Hofmeister EP, Leak RS, Culp RW, et al.: Arthroscopic hemitrapeziectomy for first carpometacarpal
arthritis: results at 7 year follow up. Hand 4(1): 24-28, 2009.
28. Cox CA, Zlotolow DA, Yao J: Suture button suspensionplasty after arthroscopic hemitrapeziectomy for
treatment of thumb carpometacarpal arthritis. Arthroscopy 26(10): 1395-1403, 2010.
Chapter 26B
Severe Arthritis Treated by Total Trapezium Excision and Soft-
Tissue Reconstruction
Mark C. Shreve
Steven D. Maschke
INTRODUCTION
Thumb basilar joint arthritis is a frequent cause of radial-sided wrist pain and a common pathologic entity in the
United States affecting most often women in their fifth to seventh decades of life. Radiographic evidence of
thumb carpometacarpal (CMC) arthritis is present in 25% of men and 40% of women over the age of 75 years
(1). Despite this high prevalence of radiographic disease, not all patients experience pain or disability (2). Eaton
described the stages of thumb CMC arthritis ranging from a normally appearing joint on radiographs with mild
widening of the joint space, to severe arthritic changes and pantrapezial involvement (3,4). Patients at each of
the stages of CMC arthritis may experience pain, instability, and limitations in thumb motion and prehensile
function due to their basilar joint disease.
After nonsurgical treatment with anti-inflammatory medications, therapy, splinting, and injections has failed to
provide adequate pain relief and function, operative management can be explored. In order to restore a pain-
free, stable, and functional thumb, many different surgical procedures have been described. First described by
Gervis (5) in 1949, simple excision of the trapezium has become a mainstay of operative treatment for thumb
basal joint arthritis. Froimson (6) later described adding an interposition arthroplasty into the space created by
excision of the trapezium to prevent subsidence of the first metacarpal. Eaton and Littler (4) described volar
ligament reconstruction using the flexor carpi radialis tendon to treat mild basal joint arthritis. Burton and
Pellegrini (7) further modified simple trapeziectomy by adding a ligament reconstruction in addition to a tendon
interposition, which has become the most widely performed operation for thumb basal joint arthritis. Other
procedures range from partial trapeziectomy, first metacarpal osteotomy, basal joint arthroscopy, and implant
arthroplasty, which are detailed in other sections of this book. This chapter describes our technique of trapezial
excision with ligament reconstruction and tendon interposition.
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When deciding which surgical procedure is appropriate for a patient, it is important to determine the clinical stage
of basilar joint arthritis. The most widely used staging system is that of Eaton and Glickel (3,8). Although recently
the interobserver reliability has been called into question (9,10), it is still a useful tool, especially when discussing
diagnosis and treatment options with patients. Stage I disease is defined by either normal radiographs or thumb
CMC joint space widening due to synovitis. Patients in this stage are often times younger and have pain due to
excessive basal joint laxity. Stage II is manifested by the beginnings of thumb CMC joint space narrowing with
osteophytes and/or loose body formation less than 2 mm. Stage II patients are typically in their fourth and fifth
decades. Stage III arthritis is manifested by significant CMC joint space narrowing or complete joint space
destruction with osteophytes and loose body formation more than 2 mm. These patients are typically older,
active adults in their fifth through seventh decades and more commonly females. Finally, stage IV disease has
the same radiographic findings as stage III but with the addition of scaphotrapezial joint arthritic changes.
Indications for trapeziectomy with ligament reconstruction and tendon interposition are those patients with more
severe arthritic changes about the thumb basal joint, typically patients in stages II, III, and IV. However, we have
performed complete excision of the trapezium with ligament reconstruction in patients with radiographic stage I
disease with good long-term results.
Potential alternatives to total trapezial excision and ligament reconstruction with tendon interposition have been
described and may be considered in those patients in which the disease is limited and radiographic evidence is
at stage I. These patients are potential candidates for more limited procedures such as subtotal trapezial excision
with ligament reconstruction, joint arthroscopy, metacarpal extension osteotomy, or continued nonsurgical
management.
Patients with basal joint arthritis typically complain of pain with activities requiring repetitive pinching, gripping,
and twisting. Common complaints include difficulty with opening jars or handwriting, but vary depending on the
patient's specific occupation or hobbies with varied demands placed on individual hand function. Aesthetic
complaints of enlargement of the thumb base are common and occur secondary to gradual dorsal-radial
subluxation of the thumb metacarpal on the trapezium with increasing basal joint laxity (8). A thorough history and
physical examination is important, as often concomitant de Quervain's tenosynovitis and/or carpal tunnel
syndrome is present in patients with basal joint arthritis (11,12). Both can contribute to radial-sided wrist pain and
intrinsic thumb weakness and disability. The first dorsal compartment over the dorsal-radial aspect of the distal
radius, which contains the tendons of the abductor pollicis longus and extensor pollicis brevis, should be
evaluated for tenderness and swelling. Thorough evaluation for carpal tunnel syndrome is critical to define any
concomitant compression of the median nerve. Often, deformity from basilar joint arthritis can mask weakness of
the thenar musculature found in severe carpal tunnel syndrome. When present, concomitant carpal tunnel
syndrome and/or first compartment tendonitis should be surgically addressed at the same time as the thumb
CMC reconstruction.
Objective measurement of lateral and key pinch should be performed and compared to the opposite hand.
Evaluation of posture and function of the thumb metacarpophalangeal (MP) joint is also necessary for
preoperative planning. Observe the patient's thumb during active pinch, which will not only accentuate the dorsal
subluxation of the metacarpal base but also unmask any underlying MP joint collapse into hyperextension (Fig.
26B-1). MP hyperextension greater than 30 degrees and/or valgus instability should be addressed at the time of
surgery with either MP joint arthrodesis or volar capsulodesis (13,14,15).
Radiographic evaluation of the thumb should be performed preoperatively. Standard posteroanterior, lateral, and
oblique views should be obtained. An adequate lateral view will have the MP joint sesamoids superimposed. A
basal joint stress view can also be obtained, which is an anteroposterior view of both thumbs obtained while
having the patient press the radial aspect of the thumb tips together thus comparing the basal joint subluxation
side to side (3). These radiographs should be scrutinized for involvement of the scaphotrapeziotrapezoid (STT)
joint, as concomitant STT arthritis may alter the surgical plan.
When planning to perform ligament reconstruction and tendon interposition by harvesting the palmaris longus
tendon, it is helpful to document the presence and size of this tendon preoperatively. We ask our patients to
pinch the tips of the thumb and small finger together while flexing
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their wrist; this maneuver will define the palmaris longus when present (Fig. 26B-2). Absence of the palmaris
longus varies between ethnic groups, but is generally regarded as being absent in approximately 15% of the
population (16). When present, size can vary between patients.
FIGURE 26B-1 Clinical (A) and radiographic (B) examples of thumb MP joint hyperextension secondary to
advanced thumb CMC disease.
FIGURE 26B-2 Ask the patient to pinch the tips of the thumb and small finger together while flexing the wrist to
accentuate and determine the presence of the palmaris longus tendon (arrow).
There has been concern in the literature regarding harvest of the flexor carpi radialis tendon. Some have found
impaired flexion torque and diminished flexion fatigue resistance after full FCR tendon harvest (17), while others
have found no impairment postoperatively (18). Recently, Beall et al. (19) noted that 79% of patients at least
partially regenerated their FCR tendon after full harvest based on MRI studies performed postoperatively. In
practice, we routinely harvest the entire FCR tendon and have not experienced complaints of subjective pain or
weakness.
TECHNIQUE
Trapeziectomy and soft-tissue reconstruction can be performed under regional or general anesthesia. Regional
anesthesia is preferred utilizing an axillary nerve block with sedation intraoperatively. This offers several
advantages, including prolonged pain relief, less nausea associated with general anesthesia, and improved
overall patient satisfaction.
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The patient is placed supine on a standard operating room table with the arm abducted and positioned onto an
attached hand table. A well-padded tourniquet is placed on the upper brachium. After administration of
perioperative antibiotics, the limb is exsanguinated and the tourniquet inflated to typically 250 mm Hg or at least
100 mm Hg above the systolic blood pressure.
A longitudinal incision is centered on the dorsum of the thumb CMC joint extending 1cm both proximally and
distally (Fig. 26B-3). Once the skin is incised, superficial bleeding vessels are contained using bipolar cautery.
Great care is taken to bluntly dissect the subcutaneous tissues and identify branches of the superficial radial
nerve as they course in a proximal to distal direction in line with the incision. Once the sensory nerves are
identified, they are gently retracted with a blunt retractor and protected for the remainder of the surgery.
Superficial nerve injury is a common cause of continued pain and dissatisfaction postoperatively.
The tendons of the abductor pollicis longus and the extensor pollicis brevis are identified. Typically, the CMC
joint is approached just dorsal to the tendon of the extensor pollicis brevis, but may also be exposed between the
two tendons of the first dorsal compartment (we utilize the approach that gives us the best access to the
articulation and is dependent upon each patient's unique anatomy). The tendons of the first dorsal compartment
(EPB and APL) are then retracted revealing the underlying radial artery coursing deep to these tendons on its
way to supply the deep palmar arch. The artery is bluntly dissected and mobilized dorsally away from the
scaphotrapezial joint using a blunt retractor. There are several branches of the artery to the joint capsule that will
need to be cauterized using the bipolar in order to safely mobilize the radial artery. This proximal exposure aids
in our capsular repair at the conclusion of the reconstruction.
The capsule of the CMC joint is exposed and incised longitudinally starting 1 cm distal to the base of the thumb
metacarpal and continuing to the distal edge of the ST joint. We take care to raise fullthickness capsular flaps
when exposing the trapezium. Strong and stable capsular closure at the conclusion of the operation will enhance
stability and positioning of the thumb joint postoperatively. With the trapezium exposed and dissected, a small
microsagittal saw is utilized to divide the trapezium longitudinally in line with the underlying course of the FCR
tendon. An osteotome completes the cut, taking care not to damage the underlying FCR tendon. Removing the
halved trapezium can be challenging. We utilize a small rongeur and incorporate a combination of twisting and
sharp dissection of the underlying joint capsule. Do not hesitate to divide the remaining bone into smaller pieces
to facilitate safe removal. Once the trapezium is completely excised, be sure to remove all loose bodies,
especially those that may have tracked up the FCR sheath along the undersurface of the thumb metacarpal
base. Careful inspection distally between the base of the first and second metacarpals will often reveal a large
osteophyte requiring removal. At this point, inspect the scaphotrapezoidal joint by gentle distraction of the index
finger. If there are concomitant arthritic changes on radiographs and/or visual inspection, the proximal 2 to 3 mm
of the trapezoid can be removed with an osteotome or microsagittal saw.
After complete excision of the trapezium, a 3-0 nonabsorbable suture is placed into the underlying joint capsule,
which will be used later to secure the interposition tissue into the trapezial void. Next, carefully dissect the
remaining capsule and periosteum from the dorsal base of the thumb metacarpal. Using sequentially larger sized
drill bits, make an oblique hole in the base of the thumb metacarpal from a dorsal distal to proximal palmar
orientation, aiming to have the exiting drill bit just dorsal to the palmar lip of the thumb metacarpal base. This can
be facilitated by holding the thumb with slight traction and having an assistant use a Freer elevator or osteotome
to elevate the base of the thumb metacarpal, which also acts to stabilize the bone (Fig. 26B-4). The size of the
hole is dependent upon the
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size of the patient's thumb metacarpal and FCR/palmaris longus tendon. Be sure to debride the sharp edges of
the drill holes in order to create a smooth surface, thus avoiding abrasion of the passed tendon.
FIGURE 26B-3 Preferred incision for CMC arthroplasty.
Depending on desired technique, either the FCR tendon is detached proximally or a section of the palmaris
longus tendon is harvested. When using the FCR tendon for the ligament reconstruction, a 2-cm transverse
incision is made at the myotendinous junction in the midforearm. The FCR tendon is visualized, confirmed with
gentle traction, and dissected. Next, sharply incise the tendon transversely with a scalpel at the myotendinous
junction. Carefully dissect any adhesions around the tendon edge that may impede further retraction of the
tendon distally.
When performing the operation using the palmaris longus tendon, a 1-cm transverse incision is made just
proximal to the wrist crease centered over the palmaris longus. Identify the tendon and sharply detach
transversely with a scalpel. Note: The median nerve lies directly beneath this tendon and must be carefully
protected. After division, place a clamp on the distal end and use a tendon stripper with slow steady pressure
proximally to harvest the tendon graft. Remove the tendon from the forearm, and debride any remaining muscle
attached to the tendon. Set the tendon aside in a moist sponge.
Next, if using the FCR tendon for ligament reconstruction, the tendon is visualized distally in the depth of the
wound and using a curved clamp is gently retracted out of the wound. Slow steady force is typically necessary to
retract the tendon, and retrieval is facilitated by meticulous dissection of the previously mentioned adhesions.
Once the FCR tendon is withdrawn distally, the size is visually inspected. When the FCR tendon is too large to
pass through the hole in the metacarpal base, it can be split longitudinally. Using a Hewson suture passer, pull
the FCR tendon through the hole in the base of the thumb metacarpal from palmar proximal to dorsal distal.
Place a rolled towel in the hand to keep the thumb in an abducted and extended position while tensioning. Small
right angle retractors work well in maintaining the space while tensioning the reconstruction (Fig. 26B-5).
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Loop the end of the FCR tendon back around itself palmarly, confirm tension and thumb posture, and place a 3-0
braided nonabsorbable suture in a figure-of-eight fashion through the tendon to secure. Next, using the suture
placed previously in the base of the capsule, sequentially thread the FCR tendon creating a ball of tendon that is
then tied in order to secure the interposition in the trapezial void. We typically do not supplement our
reconstruction with a temporary K-wire unless indicated by instability or poor soft-tissue quality.
FIGURE 26B-4 Drilling of the metacarpal. Stabilizing the base of the thumb metacarpal with a flat elevator aids in
visualization and correct placement and orientation.
FIGURE 26B-5 Trapezium excised and space maintained with right-angled retractors.
If using the palmaris longus tendon for ligament reconstruction, pass the tendon around the FCR tendon in the
base of the wound. Bring the distal end of the palmaris tendon through the hole in the base of the thumb
metacarpal from palmar proximal to dorsal distal. Place a rolled towel in the hand to position the thumb in
abduction and extension. Tie the two ends of the palmaris tendon graft in a square knot, setting the appropriate
tension on the ligament reconstruction, and place a 3-0 braided nonabsorbable suture in a figure-of-eight fashion
in the knot to secure (Fig. 26B-6). Continue tying square knots with the ends of the palmaris longus tendon to
create a tight ball of tendon graft. Then, using the suture previously placed in the capsule at the base of the
wound, pass this suture through the ball of tissue and tie it down into the trapezial void, thus completing the
interposition (Fig. 26B-7).
FIGURE 26B-6 Ligament reconstruction using a free palmaris longus tendon graft. The tendon knot will be
secured with 3-0 braided suture.
FIGURE 26B-7 Completed thumb reconstruction prior to capsular closure.
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Next, reevaluate the thumb MP joint. If greater than 30 degrees of hyperextension is present, perform either a
volar capsulodesis utilizing suture anchors or an MP arthrodesis using any number of techniques including plate
fixation, K-wire tension band (our choice), or intramedullary screws.
Regardless of which tendon graft is used, palmaris longus or FCR, closure is the same. The thick capsular flaps
are tightly closed in an interrupted fashion using a 3-0 braided absorbable suture. A “pants over vest” technique
is employed to further secure and stabilize the reconstruction. Release the tourniquet and control any bleeding
vessels using bipolar cautery. The subcutaneous tissue is closed with interrupted buried absorbable sutures and
the skin with a running absorbable suture. A well-padded thumb spica splint is placed with the wrist in slight
extension and the thumb in a position of abduction with the MP joint in 15 to 20 degrees of flexion and the IP joint
free.
PEARLS AND PITFALLS

Inspect the patient for presence or absence of a palmaris longus tendon preoperatively, and evaluate its size
to determine if it will be of adequate bulk for use as tendon graft and interposition tissue.
Fully mobilize and protect the radial artery in the dorsal-radial aspect of the wound.
Thick capsular flaps are critical for closure, stabilization, and containment of the tendon interposition at the
conclusion of the procedure.
Avoid injury to the FCR tendon underneath the trapezium during trapeziectomy. Make cuts in line with the
fibers of the FCR when using the saw/osteotome, and take care not to injure when using the scalpel to free up
remaining pieces of trapezium.
Inspect the cul-de-sac between and volar to the thumb and index metacarpal bases for any loose bodies, as
this is a common area from which they may be missed.
Inspect the scaphotrapezoidal joint for arthritic degeneration as this is a common site of continued pain after
trapeziectomy and soft-tissue reconstruction.
Remember to place a suture in the joint capsule in the depth of the trapezial void prior to tendon transfer and
interposition in order to facilitate the ease of securing the interposition graft in the trapezial void created with
trapeziectomy.
Ensure adequate position of the thumb while tensioning and suturing the ligament reconstruction. We find it
helpful to place a rolled towel in the patient's hand as this places the thumb in the correct amount of abduction
and extension.
The patient is placed in a well-padded thumb spica splint at the conclusion of the surgery. The thumb is
positioned in abduction, with the MP joint flexed 15 to 20 degrees and the IP joint free. The MP and IP joints of
the remaining fingers are left free to encourage early mobilization. The initial postoperative visit occurs at 1 week
and consists of splint removal, inspection of the wound, swelling and posture of the thumb, and application of a
short arm thumb spica cast maintaining the same position as above. Four weeks postoperatively, we discontinue
the cast and initiate occupational therapy. The hand therapist fashions a removable thumb spica splint and
instructs the patient on early mobilization, edema control, and scar management. Discontinuation of the splint
and progressive strengthening begins at the 8-week postoperative visit. Full use is allowed at 3 months, but the
patients are educated on the continued improvements they should expect with regard to strength, pain relief, and
overall function for up to 18 months postoperatively.
COMPLICATIONS
Trapeziectomy with soft-tissue reconstruction involving ligament reconstruction and tendon interposition is
not without complications (20). The most common complications, although rare, include nerve injury, thumb
metacarpal base subsidence and instability, graft extrusion, late MP joint collapse, thumb metacarpal base
fractures, scar contracture and tenderness, complex regional pain syndrome, and wound infections
(8,20,21,22).
Injury to the superficial radial nerve branches can be prevented by identification of the nerves during the
surgical approach and gentle retraction. Graft extrusion is uncommon, and the risk is diminished by
ensuring an adequate capsular closure and maintaining thick capsular flaps when dissecting around the
trapezium (21).
Arthritic changes at the scaphotrapezio-trapezoidal joint are present on radiographs 60% of the time (23),
and it is important to note this preoperatively and intraoperatively and treat at the time of surgery. Failure to
recognize this can result in continued pain postoperatively.
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Although more common with ligament reconstruction involving the abductor pollicis longus tendon (24),
preexisting de Quervain's tenosynovitis can be a cause of continued pain postoperatively. Preoperative
identification and surgical release of the first dorsal compartment should be performed if necessary.
RESULTS
It is important to convey to patients that the recovery period after trapeziectomy with ligament reconstruction
and tendon interposition is long and return of strength and pain relief can take up to 18 months. The results
of this procedure have been excellent in the literature, although some investigators have found little benefit
of added ligament reconstruction and tendon interposition over trapeziectomy alone (25,26,27).
Recently, Vermeulen et al. (28) investigated trapeziectomy with ligament reconstruction and tendon
interposition versus trapeziometacarpal arthrodesis in a prospective randomized trial in patients over 40
years of age. The study was stopped prematurely due to the alarmingly higher rate of complications in
patients having arthrodesis (71% vs. 29%), and they recommended against using trapeziometacarpal
arthrodesis in treating women with stage II or stage III basal joint arthritis.
The same author (29), in a recent randomized controlled trial, compared the technique of Weilby (24), in
which no bone tunnel is created and the tendon graft is wrapped around the APL, and the technique of
Burton and Pellegrini (7), in which a bone tunnel is created in the thumb metacarpal base to pass the
tendon graft through (as described above). They found that patients in which bone tunnels were created
had less pain and better function at 3 months postoperatively. However, those differences in functional
outcome diminished at 12 months, and final outcome was the same. They recommended using bone
tunnels due to the early favorable results.
Gangopadhyay et al. (30) prospectively randomized patients to undergo trapeziectomy alone, trapeziectomy
with tendon interposition using palmaris longus, and trapeziectomy with ligament reconstruction and tendon
interposition using FCR. With a minimum of 5 years of follow-up, average 6 years (range 5 to 18 years),
they had good results in 78% of the patients. Grip strength and key pinch strength did not differ among the
3 groups, and range of motion of the thumb was similar between the groups. They did find that the key
pinch, tip pinch, and grip strength improved from preoperatively at 1-year follow-up, but these results
deteriorated at final follow-up. However, strength testing at final follow-up was better than the preoperative
values. No significant differences in complications were seen between the 3 groups.
Lastly, Wolf and Delaronde (31) recently performed a survey of the current treatment trends of hand
surgeons in the United States. They found that the majority of hand surgeons use corticosteroid injections
for the treatment of basal joint arthritis. For stage I arthritis, 46% would continue nonoperative management
with injections and splinting. For stage III arthritis, 62% of surgeons prefer trapeziectomy with ligament
reconstruction and tendon interposition versus 8% for trapeziectomy alone. Fifty percent reported using the
whole FCR tendon versus 34% using only half of the tendon.
REFERENCES
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post-menopausal women. J Hand Surg Br 19: 340-341, 1994.
2. Patel TJ, Beredjiklian PK, Matzon JL: Trapeziometacarpal joint arthritis. Curr Rev Musculoskelet Med 6:
1-8, 2013.
3. Eaton RG, Glickel SZ: Trapeziometacarpal osteoarthritis. Staging as a rationale for treatment. Hand Clin
3: 455-471, 1987.
4. Eaton RG, Littler JW. Ligament reconstruction for the painful thumb carpometacarpal joint. J Bone Joint
Surg Am 55: 1655-1666, 1973.
5. Gervis WH: Excision of the trapezium for osteoarthritis of the trapezio-metacarpal joint. J Bone Joint Surg
Br 31B: 537-539, 1949.
6. Froimson AI: Tendon arthroplasty of the trapeziometacarpal joint. Clin Orthop Relat Res 70: 191-199,
1970.
7. Burton RI, Pellegrini VD Jr: Surgical management of basal joint arthritis of the thumb. Part II. Ligament
reconstruction with tendon interposition arthroplasty. J Hand Surg Am 11: 324-332, 1986.
8. Barron OA, Catalano LW: Thumb basal joint arthritis. In: Wolfe SW, Pederson WC, Hotchkiss RN, Kozin
SH, eds. Green's operative hand surgery. 6th ed. New York, Churchill Livingstone, 2010, Vol. 2: 410-426.
9. Berger AJ, Momeni A, Ladd AL: Intra- and interobserver reliability of the Eaton classification for
trapeziometacarpal arthritis: a systematic review. Clin Orthop Relat Res 472: 1155-1159, 2014.
10. Spaans AJ, van Laarhoven CM, Schuurman AH, et al.: Interobserver agreement of the Eaton-Littler
classification system and treatment strategy of thumb carpometacarpal joint osteoarthritis. J Hand Surg Am
36: 1467-1470, 2011.
11. Burton RI: Complications following surgery on the basal joint of the thumb. Hand Clin 2: 265-269, 1986.
12. Florack TM, Miller RJ, Pellegrini VD, et al.: The prevalence of carpal tunnel syndrome in patients with
basal joint arthritis of the thumb. J Hand Surg Am 17: 624-630, 1992.
13. Elfar JC, Burton RI: Ligament reconstruction and tendon interposition for thumb basal arthritis. Hand Clin
29: 15-25, 2013.
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14. Brogan DM, Kakar S: Metacarpophalangeal joint hyperextension and the treatment of thumb basilar joint
arthritis. J Hand Surg Am 37: 837-838, 2012.
15. Moineau G, Richou J, Liot M, et al.: Prognostic factors for the recovery of hand function following
trapeziectomy with ligamentoplasty stabilisation. Orthop Traumatol Surg Res 95: 352-358, 2009.
16. Sebastin SJ, Puhaindran ME, Lim AY, et al.: The prevalence of absence of the palmaris longus—a study
in a Chinese population and a review of the literature. J Hand Surg Br 30: 525-527, 2005.
17. Naidu SH, Poole J, Horne A: Entire flexor carpi radialis tendon harvest for thumb carpometacarpal
arthroplasty alters wrist kinetics. J Hand Surg Am 31: 1171-1175, 2006.
18. Tomaino MM, Coleman K: Use of the entire width of the flexor carpi radialis tendon for the ligament
reconstruction tendon interposition arthroplasty does not impair wrist function. Am J Orthop 29: 283-284,
2000.
19. Beall DP, Ritchie ER, Campbell SE, et al.: Magnetic resonance imaging appearance of the flexor carpi
radialis tendon after harvest in ligamentous reconstruction tendon interposition arthroplasty. Skeletal Radiol
35: 144-148, 2006.
20. Rhee PC, Shin AY: Complications of trapeziectomy with or without suspension arthroplasty. J Hand Surg
Am 39: 781-783; quiz 4, 2014.
21. Vandeputte G, Safi H, Le Viet D: Subcutaneous herniation of tendon interposition after trapeziectomy in
three cases: explanation and implications. J Hand Surg Am 26: 444-447, 2001.
22. Jones DB Jr, Rhee PC, Shin AY, et al.: Salvage options for flexor carpi radialis tendon disruption during
ligament reconstruction and tendon interposition or suspension arthroplasty of the trapeziometacarpal joint. J
Hand Surg Am 38: 1806-1811, 2013.
23. Brown GD III, Roh MS, Strauch RJ, et al.: Radiography and visual pathology of the osteoarthritic
scaphotrapeziotrapezoidal joint, and its relationship to trapeziometacarpal osteoarthritis. J Hand Surg Am 28:
739-743, 2003.
24. Weilby A: Tendon interposition arthroplasty of the first carpo-metacarpal joint. J Hand Surg Br 13: 421-
425, 1988.
25. Davis TR, Brady O, Dias JJ: Excision of the trapezium for osteoarthritis of the trapeziometacarpal joint: a
study of the benefit of ligament reconstruction or tendon interposition. J Hand Surg Am 29: 1069-1077, 2004.
26. Kriegs-Au G, Petje G, Fojtl E, et al.: Ligament reconstruction with or without tendon interposition to treat
primary thumb carpometacarpal osteoarthritis. A prospective randomized study. J Bone Joint Surg Am 86-A:
209-218, 2004.
27. Field J, Buchanan D: To suspend or not to suspend: a randomised single blind trial of simple
trapeziectomy versus trapeziectomy and flexor carpi radialis suspension. J Hand Surg Eur Vol 32: 462-466,
2007.
28. Vermeulen GM, Brink SM, Slijper H, et al.: Trapeziometacarpal arthrodesis or trapeziectomy with ligament
reconstruction in primary trapeziometacarpal osteoarthritis: a randomized controlled trial. J Bone Joint Surg
Am 96: 726-733, 2014.
29. Vermeulen GM, Spekreijse KR, Slijper H, et al.: Comparison of arthroplasties with or without bone tunnel
creation for thumb basal joint arthritis: a randomized controlled trial. J Hand Surg Am 9: 1692-1698, 2014.
30. Gangopadhyay S, McKenna H, Burke FD, et al.: Five- to 18-year follow-up for treatment of
trapeziometacarpal osteoarthritis: a prospective comparison of excision, tendon interposition, and ligament
reconstruction and tendon interposition. J Hand Surg Am 37: 411-417, 2012.
31. Wolf JM, Delaronde S: Current trends in nonoperative and operative treatment of trapeziometacarpal
osteoarthritis: a survey of US hand surgeons. J Hand Surg Am 37: 77-82, 2012.
Chapter 27
Subtotal Palmar Fasciectomy for Dupuytren's Contracture
James W. Strickland
Limited (subtotal) palmar fasciectomy is indicated for patients with advanced contracture of one or more digits.
The procedure is designed to remove only the pathologic fascia responsible for joint contracture. Hueston
applied the term regional fasciectomy to this procedure and defined it as the removal of diseased fascia within
the area. Howard perhaps said it best when he wrote that surgery was indicated for the release of “bothersome
contractures.”
A painful or annoying palmar nodule is rarely an indication for surgery, because the potential complications of the
procedure outweigh the nuisance value of the lesion. Because metacarpophalangeal (MCP) joint deformities
almost always can be corrected, surgery at this level is less urgent than that undertaken to correct developing
contractures at the proximal interphalangeal (PIP) joint. At about 30 degrees of flexion, an isolated MCP joint
contracture begins to become annoying to
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many patients, and surgery may be appropriate. It is much more difficult to correct PIP joint contractures
secondary to Dupuytren's disease than MCP joint deformities, and the greater the magnitude of the presenting
contracture, the less likely it is that significant, long-term improvement can be achieved by surgery. The author
concurs with McFarlane that PIP surgery should be considered before joint contractures exceed 30 degrees.
Patients undergoing surgery for Dupuytren's disease should be counseled carefully about the nature of the
disease process and the prognosis for the additional contracture and functional impairment should they elect not
to proceed with surgery. The intricacies of the operation also should be reviewed, including the possibility of
complications and the need to commence early postoperative digital motion to minimize stiffness or recurrent
contracture. Make every effort to identify patients who develop a postoperative sympathetic “flare” and often the
author is more reluctant to proceed with surgery in these patients. It has been said that a moist, sweaty hand is a
bad prognostic sign, as is the thickened hand of a laborer. Alcoholics, epileptics, and patients with Dupuytren's
diaphysis (strong family history, early onset of the disease, multiple areas of fibromatosis, ectopic fibromatosis,
Peyronie's disease, knuckle pads, or foot involvement) can be expected to do less well than patients who do not
have these characteristics. In addition, there is a strong feeling that female patients are more likely to develop a
postoperative sympathetic “flare” than male patients. Although the indications for surgery are generally the same
in these patients, it may be appropriate to follow them longer to ensure that their disease is progressive and to
consider alternative methods designed to lessen the magnitude of the operative procedure, such as
subcutaneous fasciotomy or a more limited open fasciectomy.
In preparation for subtotal palmar fasciectomy, drawings are made of the position and the extent of the fascial
involvement, and accurate measurements of digital motion, including the extent of the MCP or PIP joint flexion
contractures, should be made. In some instances, radiographs may be important to rule out any arthritic
involvement of the joints one expects to mobilize during the operative procedure.
SURGERY
The author carries out all subtotal palmar fasciectomies for Dupuytren's contracture on an outpatient basis, with
the patient under axillary block anesthetic. The advantages of regional anesthesia are considerable and include
the fact that the procedure produces a sympathetic blockade, which may be of value in diminishing the incidence
of postoperative sympathetic “flare.” Most of our axillary blocks are done using bupivacaine so that patients will
have prolonged postoperative anesthesia, which will permit them to return comfortably to their homes before
experiencing any postoperative discomfort.
The axillary block is administered in a remote anesthetic area, with the provision of additional sedation
depending on the patient's desires. The patient then is brought into the regular operating room, where
preparation and draping are carried out in standard fashion.
Incisional decisions are made according to the exact location of the offending fascia. If the digital cord is midline,
the incisions will be centered over the midportion of the palmar digit. If the fascia is located more to the radial or
ulnar side of the involved digit, incisions should be centered over the fascia rather than over the digit to lessen
the amount of dissection necessary to expose the offending fascia and to decrease the often-precarious length
of the digital flaps.
Limited fasciectomy requires wide surgical exposure of the offending fascia. My goal is to release contractures of
the MCP and PIP joints fully, even if that requires concomitant capsulectomy. Incisional options include the use
of a continuous Z-plasty; multiple, long zigzag incisions as described by Brunner; or shorter, Y-shaped incisions
that are converted to V-shaped incisions to bring additional skin to the midline (Fig. 27-1). The zigzag incision
with the Y-V closure, advocated by King and associates, has the advantage of allowing mobilization of
considerable skin into the longitudinal axis of the palm and digit and is the author's preference. There is rarely a
need for skin grafting following correction of the deformity, and parallel incisions may be made if the disease
involves adjacent digits.
Subtotal palmar fasciectomy is a meticulous, technique-intensive surgical procedure (Fig. 27-2A). Incisions are
centered directly over the involved fascia, beginning at the proximal palm and extending to a level distal to the
terminal fibers of the diseased cord. If several digits are involved, carefully planned, parallel incisions may be
made continuously in the palm and digit. All incisions are drawn
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on the finger at the onset of the procedure using a skin-marking pen, following which the hand and arm are
exsanguinated with an Esmarch bandage, and the tourniquet is elevated to the appropriate pressure (100 to 150
mg greater than systolic blood pressure, not to exceed 300 mm Hg). Although many surgeons prefer to use a
magnifying loupe, magnification of greater than ×2 may hinder dissection by limiting the surgeon's field of vision.
Magnification for Dupuytren's fasciectomy is rarely used. Throughout the dissection, small bleeding vessels
should be cauterized immediately to minimize bleeding at the time of tourniquet release. Skin flaps are dissected
carefully off the underlying diseased area, and despite the intimate relationship between the fascia and its
overlying skin, a satisfactory plane always can be identified. Sharp dissection with a no. 15 blade is used, and
flaps are mobilized until the entire diseased cord has been exposed.
FIGURE 27-1 Incision options for subtotal palmar fasciectomy. The author prefers the short (two incisions per
phalangeal segment) right-angle zigzag incisions shown on the ring fingers of both drawings. They may be easily
converted to Y-V closures.
FIGURE 27-2 Illustrations of surgical technique for subtotal palmar fasciectomy. A: Palmar-digital cord of the ring
finger with contracture. B: Hand positioned on table and planned incisions are shown. C: Skin incisions and
subcutaneous dissection.
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FIGURE 27-2 (Continued ) D: Exposure of diseased fascia. E: Identification and careful dissection of
neurovascular bundles. F: Removal of diseased fascia from proximal to distal. G: Removal complete. H:
Technique of capsulectomy of the proximal interphalangeal (PIP) joint (when necessary) release or removal of
the check-rein ligaments and accessory collateral ligaments. I: Wound closure by flap advancement (Y-V). Small
catheter drainage. J: Bulky compression dressing with catheter and suction collecting tube incorporated.
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At this point, neurovascular bundles from the distal palm to the distal digital level on both the radial and ulnar
sides of the cord are exposed, and one must take particular care to identify spiral cords and to protect the
vulnerable neurovascular bundles that are delivered in a superficial and medial direction by these fascial
projections. The spiral cords arise from either the pretendinous cords or the intrinsic muscle tendons and extend
deep via the spiral band to the neurovascular bundle, displacing it both superficially and medially and rendering it
vulnerable to surgical dissection. The presence of a spiral cord often can be identified before surgery by the
observation and palpation of a large nodular, fascial accumulation eccentrically located at the base of an
involved digit. Flaps are dissected carefully off the spiral cord area, and the vulnerable nerves and vessels
should be identified early and protected thereafter.
It is usually preferable to remove the fascia en bloc in a proximal to distal fashion once the neurovascular
bundles are well exposed; however, when a spiral cord exists, or the nerve and artery are intricately involved
with the digital disease, it is preferable to remove the fascia in a piecemeal fashion to protect these structures. It
is also important to preserve as much fatty tissue as possible to provide a well-padded bed for the neurovascular
bundles at the conclusion of the procedure. Vertical septa are divided deep to the plane of the fascia, but the
author usually makes no effort to remove them at the deeper level, as they are not a cause of contracture.
When necessary, similar dissection in the adjacent palmar digital areas is carried out, and when all diseased
fascia has been excised, determine whether full joint extension has been achieved. In almost every instance, the
MCP joints are fully extensible following removal of the offending fascia, but persisting PIP joint contractures may
require capsulectomy. When capsulectomy is required at the PIP level, the technique of Watson and colleagues
is recommended. For this procedure, open the flexor tendon sheath just proximal to the A3 pulley and, with the
flexor tendons alternately retracted into the radial and ulnar sides of the digits, excise the check-rein proximal
extensions of the palmar plate. It is also possible to release the palmarmost fibers of the collateral ligament
(accessory collateral ligaments) and gently manipulate the digit to achieve full or near-full extension. Failure to
achieve full extension may require additional exploration and release of portions of the lateral digital sheet or
further V-Y skin extension incisions.
In the little finger, expose the ulnar aspect of the digit to determine whether a hypothenar cord is present. If so, it
should be excised, as it may represent the most likely cause of recurrence of deformity in that digit. Similar
isolated digital cords may be present in other digits and should be identified before surgery by the palpable
presence of a PIP joint contracture without an associated palmar fascial communication. Again, the use of zigzag
incisions centered directly over the cord will usually provide adequate exposure for cord excision, with the
realization that the neurovascular bundle is displaced medially in the proximal digit and passes underneath the
cord distally.
At the conclusion of the fascial excision and any necessary capsulectomies, the tourniquet should be released
and compression applied to the hand for 10 minutes to control the resulting wound hyperemia. At this point,
cauterize all brisk bleeders; while the tourniquet is released, carefully inspect all skin flaps to be sure that they
return adequate vascularity. If the entire flap remains white, it may be necessary to excise it and use skin graft
coverage, as that flap almost surely will be necrotic at the time of the initial dressing change. If only the distal 2 or
3 mm of the flap remain white, that segment of the flap may be excised and the flap advanced further at the time
of the wound closure. At the time of closure, do not hesitate to reinflate the tourniquet if there is a vascular ooze.
It is preferred to close the wound somewhat loosely using 5-0 nonabsorbable sutures with about two thirds the
normal number of skin sutures that might normally be used for a tight wound closure. As the wound is being
closed, introduce the tubing of a pediatric scalp vein set into each wound in a distal to proximal fashion after
several small holes have been placed along the length of the tube. After wound closure is complete, it has been
the author's habit to instill 3 to 5 mL of triamcinolone into each digital wound with a small flexible catheter. This
local steroid eliminates postoperative pain and reduces the amount of postoperative wound reaction that these
patients so commonly experience.
A bulky compressive dressing is applied in such a manner as to produce anterior/posterior compression of the
hand. The fingers are splinted into nearly full extension using a palmar plaster slab. If the tourniquet has been
reinflated, it is then deflated, and the scalp vein needle, which exits from the distal part of the dressing, is placed
in the rubber stopper of a suction collection tube. The drainage tube then can be incorporated in the outer layer
of the dressing, and an additional tube can be placed adjacent to it in case the first tube should fill. Clinical
photographs of the surgical steps of subtotal palmar fasciectomy are illustrated in Figure 27-3.
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FIGURE 27-3 Clinical photographs of subtotal palmar fasciectomy. A: Severe contracture of the fifth finger with
associated distal palmar disease proximal to ring finger. Incisions have been marked. B: Appearance of diseased
fascia with all flaps elevated. C: Identification and dissection of neurovascular bundles. D: Fascia removed from
proximal to distal. E: Appearance of digit with fascia removed (shown above digit). F: Sheath opened over
proximal interphalangeal (PIP) joint, and flexor tendons retracted in preparation for capsulectomy.
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FIGURE 27-3 (Continued ) G: Digit fully extended following capsulectomy. H: Small bleeding vessels cauterized
with tourniquet deflated. I: Skin flaps advanced before closure. J: Wound closure with drainage catheter in
place. K: Instillation of several milliliters of triamcinolone before applying dressing. L: Compression dressing with
collecting tube incorporated.
At the time of discharge, instruct both the patients and their families about the method of removing the drain from
the dressing on the following day. Any problems are to be reported to the doctor's office, and for patients who
have traveled a long distance for their surgery, they may be asked to spend the night in an adjacent lodge so the
drain can be removed on the following day before the trip home. All patients are scheduled for follow-up
appointments within 3 to 5 days of surgery, at which time the bulky dressing is removed and a vigorous digital
motion program
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initiated. Every effort is made to achieve a full range of digital motion by the time the patient leaves the facility.
Continuous extension splinting of the involved digits is maintained for several weeks, although the splint is
removed frequently for active and passive range-of-motion exercises. Skin sutures are removed at 2 weeks, and
formal therapy is instituted for patients who have difficulty with active flexion and extension. Night extension
splinting for the involved digits is currently continued for 6 to 12 months in an effort to minimize the possibility of
recurrent contractures.
The author has been impressed that patients have little or no discomfort in the immediate postoperative period,
and this may be attributable to the use of steroids in the operative wound. Some discomfort is associated with
the initial therapy, and it is not unusual for the digits to be somewhat swollen for several weeks. A complete
composite fist is sometimes quite difficult because of this digital swelling, but most patients can bring their digits
to or close to their palms at the conclusion of the initial therapy. The surgical wounds from Dupuytren's
contracture are often hypertrophic and angry looking for 4 to 8 weeks. When the patient is struggling with
postoperative exercises and the wounds are firm and hypertrophic, initiate a short course of oral steroids
(Methylprednisolone Dose Pack) for 6 days and, in some patients, extend the use of steroids for an additional 2
to 3 weeks in a low dosage, not to exceed 8 mg a day. The use of steroids for these somewhat reactive wounds
is beneficial.
For patients who experience some difficulty maintaining a satisfactory range of digital motion on their own, formal
hand therapy may be appropriate. In addition to active and passive range-ofmotion exercises and the use of
static or dynamic splints, therapists also may employ massage techniques in an attempt to soften the surgical
scar, and we find that the use of Coban elastic wrapping or small elastic digital “socks” has been helpful in
reducing edema. The inclusion of soft, custommolded materials, such as medical grade elastomer, in the contact
areas of postoperative Dupuytren's splints also has been helpful in reducing swelling and softening the surgical
scar (Fig. 27-4).
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Most important, therapists can recognize deteriorating function by serial digital measurements and wound
observations. The therapy program may be altered as a result of these changes, and frequent dialogue with the
surgeon is important so that appropriate measures can be carried out to minimize functional loss.
FIGURE 27-4 Preparation of customized digital splint inlaid with molded medical grade elastomer (Dow Corning).
A: Commercial components of elastomer. B: Material is prepared and conformed to the patient's middle and ring
fingers. C: Supporting rigid splint is bonded to elastomer. D: Appearance of splint when strapped in position.
COMPLICATIONS
The immediate potential complications of surgery for Dupuytren's contracture include palmar hematoma and
skin necrosis. The use of low suction drainage should minimize the likelihood of hematoma, but when it
occurs, prompt evacuation is recommended. Skin necrosis may be managed by careful observation if the
diameter of the area is no greater than 1 cm; however, larger areas must be excised as soon as possible.
The defect that results from excision of the necrotic skin may be left open or closed by the use of a free
graft.
A postoperative sympathetic disturbance or “flare” is probably the most severe complication after surgery
for Dupuytren's contracture. The condition is thought to be secondary to an overresponse of the
sympathetic nervous system and may be quite difficult to manage. Pain, swelling, and stiffness may involve
not only the operated digits but also the unoperated fingers, the hand, and, to some extent, the entire
extremity. Wounds may be inordinately reddened and firm, and the hand may sweat excessively. Onset of
this unfortunate complication may be suspected when the degree of pain, edema, and stiffness experienced
by the patient exceeds that normally seen during the early stages of surgical recovery.
Treatment of severe “flare” usually consists of a gentle but vigorous therapeutic program that includes
active and passive range-of-motion exercises, dynamic splinting, continuous passive motion devices,
transcutaneous nerve stimulation, and the administration of anti-inflammatory medications or steroids. Oral
steroids may be of considerable value in patients with particularly severe dystrophy characterized by
marked inflammation and stiffness. Carpal tunnel decompression is of value when the median nerve is
compromised. Occasionally, one or more stellate ganglion blocks may help to reverse this phenomenon.
When postoperative flare or dystrophy occurs, patients should be advised that their recovery will be
considerably slower than originally expected and that a great deal of patience and effort will be required to
maximize the eventual recovery. Failure to comply with the vigorous therapeutic program may result in
permanent stiffness of the involved digital joints and sometimes even of the uninvolved digits of the
operated hand.
The author concurs with the statement made many years ago by Howard that surgery for Dupuytren's
contracture is palliative rather than curative. Recurrence of diseased fascia and flexion contractures is,
unfortunately, fairly common following this procedure. Our results suggest that complete correction of the
MCP joint deformities is almost always achieved, and recurrent deformity at that level is rare. The
redevelopment of PIP joint flexion contractures is much more frequent, and these deformities often recur
fairly rapidly following surgical correction. We found that the degree of PIP joint contracture at the time of
surgery could be used to predict the likelihood of recurrence. If the presenting contracture was less than 30
degrees, long-term postoperative follow-up indicated that recurring contractures almost never exceeded 30
degrees. If the preoperative deformity was between 30 and 60 degrees, 20% of patients redeveloped
deformity that was as great as or greater than the original contracture. If the initial contracture was greater
than 60 degrees, 50% went onto recurrent severe deformity. Without question, the PIP joint of the small
finger is the most troublesome, and trying to correct and prevent the recurrence of deformity at that joint is
an enigma for all hand surgeons.
Recurrent Dupuytren's disease is common and almost always involves the PIP joint. Because of the added
difficulty in correcting recurrent contractures, the indications for additional surgery are somewhat different
from those governing the original procedure. If the degree of contracture is not great and the condition
appears to be reasonably stable, the surgeon and the patient may elect to accept the results of the initial
operation rather than to attempt surgical correction again. If, however, the contracture is severe and
progressive, additional efforts at ablation of the offending disease may be indicated. Reoperation is more
difficult, because the diseased fascia is intertwined with scar secondary to the previous surgery. As with the
original fasciectomy, complete exposure of the neurovascular bundles is required. Defining and protecting
those structures may be considerably more difficult than with the initial procedure, and digital capsulectomy
is almost always required when dealing with recurrent disease. If the skin is of good quality, it may be
retained and closed, but poor-quality skin should be excised and replaced by full-thickness skin grafts, as
advocated by Hueston. Local rotational flaps or cross-finger flaps may be employed on some occasions
when vascularized tissue is required to cover complex defects resulting from skin and fascial excision for
recurrent contracture.
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When an irreparable contracture exists at the PIP joint, several salvage operations are available. The most
rational salvage procedure is arthrodesis of the PIP joint. A sufficient wedge of dorsal bone is removed to
allow the digit to be brought into about 40 degrees of extension, and a tension band technique or Herbert
screw may be used to secure fixation. Given the fact that the MCP joint function is usually normal, a good
grasping digit can be preserved in this manner. When severe deformities (greater than 90 degrees) are
present, or for patients who request amputation because of occupational concerns or disdain for the digit,
amputation either through the proximal phalanx or by ray excision may provide a satisfactory final solution.
RECOMMENDED READING
Bruner JM: Incisions for plastic and reconstructive (non-septic) surgery of the hand. Br J Plast Surg 4: 48,
1951.
Howard LD: Dupuytren's contracture: a challenge, not a blessing. AAOS Instructional Course Lecture.
Presented at the 32nd Annual Meeting of the American Academy of Orthopaedic Surgeons (self-published),
1965.
Hueston JT: Dupuytren's contracture: the trend to conservatism. Ann R Coll Surg Engl 36: 134, 1965.
Hueston JT: In: Flynn JL, ed. Hand surgery. Baltimore, MD: Lippincott Williams & Wilkins, 1982: 797-822.
King EW, Exeter NH, Bass DM, et al.: The treatment of Dupuytren's contracture by extensive fasciectomy
through multiple Y-V plasty incisions. J Hand Surg 4: 234, 1979.
McFarlane RM: The current status of Dupuytren's disease. J Hand Surg 8: 703, 1983.
McFarlane RM. In: Green DP, ed. Operative hand surgery. New York: Churchill-Livingstone, 1983.
McFarlane RM: Patterns of the diseased fascia in the fingers in Dupuytren's contracture: displacement of the
neurovascular bundle. Plast Reconstr Surg 54: 31, 1974.
McFarlane RM, Jamieson WB: Dupuytren's contracture: the management of 100 patients. J Bone Joint Surg
Am 48-A: 1095, 1966.
McGrouther DA. In: Watson N, Smith RJ, eds. Methods and concepts in hand surgery. Boston, MA:
Butterworth and Company, 1986: 75-96.
McGrouther DA: In: Hueston JT, Tubiana R, eds. Dupuytren's disease. London, UK: Churchill-Livingstone,
1985.
McGrouther DA: The microanatomy of Dupuytren's contracture. Hand 14: 215, 1982.
Michon J: In: Hueston JT, Tubiana R, eds. Dupuytren's disease. London, UK: Churchill-Livingstone, 1985:
177-183.
Stein AMH Jr: The relation of median nerve compression to Sudeck's syndrome. Surg Gynecol Obstet 115:
713, 1962.
Strickland JW, Bassett RL: The isolated digital cord in Dupuytren's contracture: anatomy and clinical
significance. J Hand Surg Am 10: 118, 1985.
Torstrick RF, Hartwig RH, Strickland JHW: Long-term results of regional fasciectomy of Dupuytren's
contracture of the proximal interphalangeal joint. J Hand Surg 6: 297, 1981.
Watson HK, Light TR, Johnson TR: Check-rein resection for flexion contracture of the middle joint. J Hand
Surg Am 4: 67, 1970.
Chapter 28
Collagenase Injection for Dupuytren Contracture
Lawrence C. Hurst
Aaron Insel
Justin B. Mirza
INDICATIONS
Collagenase Clostridium histolyticum (CCH) (Xiaflex), Auxilium Pharmaceuticals, Inc., Chesterbrook, PA,
was U.S. FDA approved for the treatment of adult patients with Dupuytren contracture and a palpable cord
in 2010. It is an office-based, minimally invasive, nonsurgical treatment. The indications for injectable
collagenase are the same as the indications for surgical treatment of Dupuytren contractures including
Metacarpophalangeal (MP) joint contractures of greater than 20 degrees
A progressive proximal interphalangeal (PIP) contracture of greater than 20 degrees
A positive tabletop test
Contracture(s) affecting a patient's hand function and ability to perform desired tasks
First web and/or thumb contractures that interfere with pinch or grasp
CONTRAINDICATIONS
Injectable CCH is contraindicated in patients with a history of severe allergic reaction to Xiaflex or to collagenase
used in any other therapeutic application. Caution should be taken in patients with coagulation disorders or
those taking anticoagulant medications other than low-dose aspirin within 7 days prior to receiving a CCH
injection, as CCH may exacerbate the expected ecchymosis response after injection. Caution should also be
exercised in a finger that has already had surgical fasciectomy, fasciotomy, trigger finger release, or other
surgery. Previous surgery can lead to abnormal scar, adhesions, A2 pulley rupture, and occasional skin loss
especially at the base of the fifth finger. These postoperative abnormalities can increase the risk for skin tears
and tendon injuries during recurrent Dupuytren cord injection. Despite this caution, CCH can be used for
Dupuytren cords that develop after surgery when physical examination shows the skin is in good condition and
the flexor tendon sheath is intact.
PREPARATION
Initial patient evaluation consists of a thorough history and physical exam including accurate measurements of
MP and PIP contractures with a goniometer and recording the tabletop test result. When indicated by clinical
exam, plain radiographs of the hand should also be obtained to evaluate possible arthritic joints. After a patient is
assessed and deemed an appropriate candidate for injectable CCH, the procedure, risks, potential benefits, and
alternatives should be discussed. Next, appropriate paperwork is submitted
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to verify insurance benefits. The co-pay responsibilities are also reviewed with the patient. The drug will be
either shipped by a specialty pharmacy to the physician's office or ordered by the office directly from the
manufacturer, depending on the patient's insurance coverage.
Vials of CCH powder and diluent should be stored in a refrigerator at 2°C to 8°C (36°F to 46°F) in the upright
position. CCH can be maintained in cold storage until the expiration date. The CCH vials should be allowed to
come to room temperature 15 minutes before mixing. If the CCH should accidentally stay at room temperature for
more than 60 minutes, both the CCH powder and diluent should be discarded.
The patient should be briefly re-examined prior to the injection by rechecking baseline neurovascular status,
tendon status, and cord patterns. A patient with previous surgery should be assessed for possible bowstringing
of the flexor tendons that can simulate a Dupuytren cord. Finally, the pathologic cord and the targets for injection
are carefully visualized and palpated.
MIXING PROCEDURE
The mixing procedure requires two 1-cc hubless syringes with ½-inch fixed 27-gauge needle and 0.01-mL
graduations. This syringe avoids drug remaining in the needle hub while the fixed needle avoids detachment of
the needle during injection into the dense Dupuytren cord material. Remove the caps from both vials and swab
with alcohol. Insert one needle into the diluent vial and withdraw the appropriate amount of sterile diluent, 0.39
mL for an MP joint and 0.31 mL for a PIP joint (Table 28-1). The diluent is mildly viscous. Next, the diluent is
injected into the vial with lyophilized CCH powder. Discard the diluent vial and syringe used for reconstitution.
Next, gently swirl the vial until the powder is completely dissolved, which should only take a few seconds. Avoid
any vigorous shaking as this could denature the enzyme. Next, orient the vial such that the rubber stopper's
longitudinal cutout is clearly visible and insert a new 1-mL syringe with fixed 27-g needle into this cutout area
within the vial (Fig. 28-1). Withdraw the appropriate amount of reconstituted CCH depending on the joint
contracture being treated, 0.25 mL for MP and 0.20 mL for PIP. Either volume will provide an actual dose of 0.58
mg of CCH. Once in solution, the drug is quite vicious. If an air bubble occurs while drawing up the diluent, the
bubble can be removed by reinjecting the diluent into the bottle and slowly reaspirating the diluent into the
syringe.
TABLE 28-1 Volumes of Diluent and Reconstituted Collagenase for Injection
Joint Being Treated Sterile Diluent for Reconstitution Injection Volume Dose
MP 0.39 mL 0.25 mL 0.58 mg
PIP 0.31 mL 0.20 mL 0.58 mg

FIGURE 28-1 When drawing up the therapeutic CCH dose, proper position of the 27-gauge needle in the vial is
just inside the rubber stopper. This position provides access to all the diluted drug and avoids air bubbles in the
syringe.
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It has now been shown that two doses (0.58 mg + 0.58 mg) can be given simultaneously for multiple joints or
separate digits (4,18). Therefore, the “off-label” use of some of the residual drug from a single vial can be added
to the 0.58 mg dose when injecting especially thick cords or complex cord combinations such as a large “Y” cord
(central cord plus a natatory cord).
INJECTION PROCEDURE
Inject the reconstituted CCH at a location where there is maximum separation of cords from underlying flexor
tendons, that is, where cord is “bowstrung” away from the flexor tendon sheath (Fig. 28-2).
It is important to hold the cord under tension throughout the injection process to aid in accurate placement of the
collagenase within the cord (Fig. 28-3A). Ideally, tension is provided by an assistant or nurse so the surgeon has
both hands available to safely manipulate the injecting syringe (Fig. 28-3).
FIGURE 28-2 The Dupuytren cord and its relationship to the flexor tendon sheath is shown. Note cord
“bowstrings” away from the flexor sheath, particularly in the palm. Note, the ultrasound verified distances
between the skin and flexor sheath in the palm and finger. Skin to sheath distance is 7 mm in palm and 2 to 4 mm
at PIP joint.
FIGURE 28-3 A: Proper positioning of the digit by an assistant during injection of CCH. Surgeon placing first
drug aliquot in distal central cord but avoids area near PIP joint flexion skin crease. B: Surgeon pushes plunger
while stabilizing syringe barrel with opposite hand. Assistant maintains tension on cord.
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Before injection, using sterile technique, prepare the volar skin of the palm and finger with your preferred skin
prep. Place the needle into the first cord target while holding the syringe with the dominant hand. Typically, the
dose can be divided into three to six aliquots. The thick dense cord material can be felt with the tip of the needle
as the needle passes from the subcutaneous tissues into the Dupuytren cord material. Once the needle is within
the cord, stabilize the syringe barrel with the nondominant hand and depress the plunger with the dominant
hand, injecting approximately one third of the dose (aliquot) into the cord at this first target location. Do not allow
the needle to advance as the plunger is compressed during injection. Any needle that passes dorsal to the cord
should be withdrawn and repositioned before injecting the aliquot. There will be resistance as the collagenase is
injected if the needle is appropriately within the cord center. The needle should then be withdrawn completely
and a new skin insertion for the next aliquot is used 2 to 3 mm distal to the first. Again, stabilize the syringe and
inject the next one-third of collagenase. Lastly, withdraw the needle completely and insert into the cord 2 to 3 mm
proximal to the first injection site, stabilize the syringe, and inject the final one-third of the dose (Fig. 28-4).
For thin to average diameter cords, the CCH aliquots are placed into the cord in a longitudinal proximal to distal
pattern (Fig. 28-5). For very thick cords, a transverse placement of the CCH aliquots is advisable (Fig. 28-6).
Usually, dividing the dose into three aliquots as described is appropriate; however, for more complex cord
patterns, the dose can be divided into 4 to 6 aliquots. In all cord types, it is critical to avoid injecting into the flexor
tendon sheath or flexor tendons.
There are special considerations when treating Dupuytren cords that contract the PIP joint of the small finger:
Do not inject more than 4 mm distal to the first palmar-digital crease.

If possible, don't insert the needle more than 2 to 3 mm into the skin. Remember the bevel of the 27-gauge
needle is approximately 1.25 mm in length.
When fifth finger superficial central cords are located over the distal half of the proximal phalanx, the flexor
tendons can be protected by orientating the needle in a transverse ulnar to radial direction during the injections
of the CCH aliquots.
A vertical insertion into the cord is appropriate for abductor digiti minimi cords, which lie ulnar, parallel, and
adjacent to the flexor sheath.
Special considerations are also appropriate when treating complex Dupuytren cord combinations. The injection
sites must be defined by careful analysis of the Dupuytren cord patterns (Fig. 28-7A-F).
FIGURE 28-4 Injection technique drawing. Needle placement in fifth finger. Needle position in cord and insert
shows longitudinal pattern of dose aliquots.
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FIGURE 28-5 Needle positions in an actual central cord.

FIGURE 28-6 Cord thickness plays a role in aliquot injection pattern. For a thin cord, a longitudinal pattern is
appropriate, but in a thick cord, a transverse pattern should be used.
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FIGURE 28-7 A: Central cord and longitudinal pattern of targets (green dots) for a single dose divided into three
aliquots. B: “Y” cord (central cord and a single natatory cord) and targets (green dots) for single dose divided in
three aliquots. C: Super “Y” cord (central cord in palm only with natatory cords radially and ulnarly going to
adjacent fingers). Injection targets for a single dose divided into three aliquots. D: Crow foot cord (central cord
and two natatory cords contracting three fingers). Appropriate targets (green dots) for a single dose divided into
four aliquots. E: Abductor digiti minimi cord and target locations (green dots). Injection sites kept in proximal half
of the cord. F: Complex cord combination and targets for a single dose (green dots) divided into six aliquots.
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POSTINJECTION MANAGEMENT
After the injection, place the patient's hand in a soft, bulky dressing. Instruct the patient to elevate the hand and
avoid forceful use of the injected digits. Avoid ice packs because cold may adversely affect the CCH enzyme's
function. Also, avoid heat packs as heat may interfere with the enzyme's function. It is important to educate the
patient that swelling, bruising, lymphadenopathy at the elbow and/or axilla, and mild discomfort at the injection
site are all typical and may occasionally progress proximally. After injection, the patient should remain in the
office for 15 to 20 minutes as a precaution to monitor the patient for any signs of allergic reaction.
FINGER MANIPULATION PROCEDURE (FINGER EXTENSION PROCEDURE)

In the initial studies (CORD I and CORD II), all patients underwent manipulation 24 hours after CCH injection.
However, this can be logistically challenging for both doctor and patient as it requires back-to-back office visits
and usually precludes injections on Fridays. Recent literature has shown that this manipulation may take place
anywhere from 24 to 96 hours after injection with no change in the safety or efficacy of collagenase treatment
(10,18). When the patient returns to the office, remove all bandages. Prior to manipulation, inspect the hand for
swelling and ecchymosis and examine the flexor and extensor tendon function. Also, evaluate the patient's
capillary refill and sensation before proceeding. In some cases, the cords may have ruptured spontaneously prior
to any attempted manipulations, but the formal manipulation under local anesthesia should still be attempted to
see if additional gains in motion can be achieved. In the clinical trials (8), no local anesthetic was injected prior to
manipulation. In clinical practice, use of local anesthetic is appropriate to minimize patient discomfort and allow
for greater success with manipulation. The senior author (LH) performs a slowly administered field block with 9
mL 1% lidocaine buffered with 1 mL sodium bicarbonate (8.4%) injected with a 27-gauge needle. This should be
done 5 to 10 minutes before any attempted manipulation. To help minimize the risk of skin tears and flexor
tendon rupture, maintain the wrist in mild flexion and the forearm in mild supination throughout the manipulation
procedure. The proper finger manipulation (finger extension) procedure sequence should be
1. Holding the PIP flexed, while extending the MP joint.

2. Holding the MP flexed, while extending the PIP joint.
3. Gently extend the PIP and MP simultaneously.
4. While holding the PIP and MP maximally extended, firmly push with the operator's index or thumb on any
residual palpable cords or nodules (Fig. 28-8).
FIGURE 28-8 Four-step manipulation technique (finger extension procedure). A gentle but firm approach is
warranted. Avoid undue pressure on any skin with postinjection blisters.
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When the manipulation procedure is concluded, place the hand in the tabletop test position to verify that the
hand can be fully extended on the flat surface. If the tabletop test remains positive, occasionally, pressure on the
dorsal MP joint area of the remaining contracted digit will help disrupt the residual cord material. The cords may
break with an audible or palpable pop. After manipulation is complete, the patient is instructed to make a fist and
then extend all of his/her fingers to demonstrate tendon integrity.
POSTMANIPULATION MANAGEMENT
After manipulation, a removable extension splint is applied to the forearm, wrist, and hand to keep the
manipulative digits comfortably extended. This splint is worn until the next morning. In the morning, it is removed
so the hand can be washed, exercised, and used as tolerated. Patients are instructed to use the extension splint
nightly for approximately 3 months. It is also important that patients have instructions for a daily at-home exercise
program to improve the range of motion, minimize residual contractures, reduce edema, and strengthen the
hand. Each patient is given a follow-up visit 3 days following the manipulation. At that point, the patient is
assessed and referral to formal hand therapy is prescribed if needed. After this initial follow-up, the patient's
progress is assessed at 2 and 4 weeks. At these follow-up evaluations, the treated finger active and passive
range of motion is assessed. The need for a second injection is also reviewed. Injections and manipulations
should be spaced at monthly intervals. Dupuytren cords can receive 3 separate injections; however, repeat
injections are rarely needed if local anesthesia is used for manipulation. In clinical trials (8), the primary endpoint
was an essentially straight finger (extension equal to 0 to 5 degrees). However, in clinical practice, patients with
a single cord rarely need a second injection to achieve a clinically acceptable result that provides excellent
function.
If skin tears occur during finger manipulation, bleeding can be controlled easily by direct pressure. Occasionally,
silver nitrate is also applied. The skin tear is covered with a nonadherent dressing and gauze. With standard
wound care and regular dressing changes, these wounds heal remarkably fast. These skin tears do not require
suturing or skin grafting. By employing the gentle four-step manipulation techniques described above, the senior
author (LH) has a skin tear rate of 15% to 18% (n = approximately 900) but the average size is very small (5 mm
× 3 mm). The small skin tears usually heal within 7 to 21 days. The maximum skin tear seen was 19 × 10 mm
and also healed quickly without further intervention. The surgeon should be especially gentle when manipulating
injected digits with blood blisters. These blood blisters can break and become skin tears.
PEARLS AND PITFALLS

Inject the cord at the point of maximal separation between the cord and underlying flexor tendon sheath to
avoid accidental injection into flexor tendon sheath.
Place the needle into the cord NOT through the cord.
Special care should be taken when treating the PIP joint of the small finger as tendon ruptures have occurred
with CCH injection at this specific location.
Do not to inject more than 4 mm distal to the proximal palmar-digital crease at the base of the finger.
Needle injection should rarely be more than 2 to 3 mm in depth.
When injecting complex cord combinations, junctions of the component cords are excellent injection targets.
COMPLICATIONS
CCH injection and finger manipulation are minimally invasive and effective procedures with excellent safety
profiles. Almost all patients will experience treatment-related events, which were seen during the
developmental clinical trials. However, these are typically mild in severity and resolve spontaneously
without any intervention. This list includes skin tears, contusion, peripheral edema, pain in extremity,
swelling, lymphadenopathy, hematoma, injection site pain, injection site hematoma, and ecchymosis of the
hand and upper extremity (Fig. 28-9).
Severe, adverse, treatment-related complications can occur but are extremely rare. In the period from
February 2010 to February 2013, there has been 49,078 CCH injections for Dupuytren's with a palpable
cord (16,25). In that time period, voluntary reporting of adverse events to the manufacturer has shown 26
tendon ruptures (0.05% incidence), one A2 pulley injury, one ligament injury, and one stretch neurapraxia
(numbness without pain away from the injection site after full extension). There has been one case of
anaphylaxis reported in a patient receiving home oxygen in the
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postmarketing double-dose study in 2013 who was successfully treated during an ER visit (25). No
permanent nerve damage or deaths have been reported with the use of collagenase at the time of this
publication.
FIGURE 28-9 Ecchymosis in a patient (A) who was injected while on Coumadin, which spontaneously
resolved in 2 weeks (B).
RESULTS
The CORD I study was a prospective, randomized, double-blind, placebo-controlled, multicenter trial of 741
injections given to 308 patients (8). The CCH injection group had significant improvements in range of
motion compared with the placebo (from 43.9 to 80.7 degrees vs. 45.3 to 49.5). In this same study,
significantly more cords injected with CCH met the primary endpoint, reduction in joint contracture to 0 to 5
degrees, compared to the placebo (64% vs. 6.8%). The study concluded that the CCH significantly reduced
contractures and improved range of motion in patients with Dupuytren contractures. Several studies have
replicated these excellent results (3,6,10,17,18,23-25). Recently, a study has also shown the efficacy and
safety of injecting two (0.58 mg) doses simultaneously for multiple joint contractures (18). This simultaneous
administration of two 0.58 mg doses has also recently been approved by the U.S. Food and Drug
Administration.
In addition, CCH injection has been compared to surgical fasciectomy and percutaneous needle fasciotomy,
two of the most commonly practiced treatment methods for Dupuytren contracture. In a direct comparison
between CCH and fasciectomy, one study found similar clinical outcomes, functional metrics, and overall
patient satisfaction at 2 years (14). However, they did find that CCH allowed for significantly faster return to
work and daily activities compared to fasciectomy. Early reports have shown CCH treatment for Dupuytren
contracture to be as effective as percutaneous needle fasciotomy with similar safety profiles (15,20) except
CCH has had only a few temporary nerve injuries and less recurrence than percutaneous needle
fasciotomy (16,22). CCH treatment provides a noninvasive treatment option with fast recovery and early
return to work.
MANUFACTURERS PRESCRIBING RECOMMENDATIONS
The manufacturer's full prescribing information for collagenase injection is at https://www.xiaflex.
com/_assets/pdf/Xiaflex-PI-Med-Guide.pdf, and the obligatory training video is at http://xiaflexrems. dnsalias.net/.
Full knowledge of these resources is paramount to the safe and effective use of injectable CCH. The technical
tips within this chapter are intended to supplement but by no means replace the manufacturer's prescribing
information and training video.
RECOMMENDED READING
Badalamente MA, Hurst LC: Enzyme injection as nonsurgical treatment of Dupuytren disease. J Hand Surg
Am 25: 629-636, 2000.
Badalamente MA, Hurst LC, Hentz VR: Collagen as a clinical target: non operative treatment of Dupuytren
disease. J Hand Surg Am 27: 788-798, 2002.
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Badalamente MA, Hurst LC: Efficacy and safety of injectable mixed collagenase subtypes in the treatment of
Dupuytren contracture. J Hand Surg Am 32: 767-774, 2007.
Coleman S, Gilpin D, Kaplan FT, et al.: Efficacy and safety of concurrent collagenase Clostridium
histolyticum injections for multiple Dupuytren contractures. J Hand Surg Am 39(1): 57-64, 2014.
Desai SS, Hentz VR: The treatment of Dupuytren disease. J Hand Surg Am 36(5): 936e942, 2011.
Gilpin D, Coleman S, Hall S, et al.: Injectable collagenase Clostridium histolyticum: a new nonsurgical
treatment for Dupuytren disease. J Hand Surg Am 35A: 2027-2038, 2010.
Hurst LC, Badalamente MA: Nonoperative treatment of Dupuytren disease. Hand Clin 15: 97-107, 1999.
Hurst LC, Badalamante MA, Hentz VR, et al.: Injectable collagenase Clostridium histolyticum for Dupuytren
contracture. N Engl J Med 361(3): 968-979, 2009.
Hurst L. Dupuytren contracture. In: Wolfe SW, Hotchkiss RN, Pederson WC, et al., eds. Green's operative
hand surgery. 6th ed. Philadelphia, PA: Churchill Livingstone, 2011: 141e158.
Kaplan TD, Badalamente MA, Hurst LC, et al.: Delayed manipulation after collagenase Clostridium
histolyticum injection for Dupuytren contracture. Hand, 2015. Paper accepted and in press.
King ICC, Belcher HJCR: Cold intolerance following collagenase Clostridium histolyticum treatment for
Dupuytren contracture. J Hand Surg Am 39(4): 808-809, 2014.
McFarlane RM, Jamieson WG: Dupuytren contracture: the management of one hundred patients. J Bone
Joint Surg Am 48: 1095-2105, 1966.
Meals RA, Hentz VR: Technical tips for collagenase injection treatment for Dupuytren contracture. J Hand
Surg Am 39(6): 1195-1200, 2014.
Naam NH: Functional outcome of collagenase injections compared with fasciectomy in treatment of
Dupuytren contracture. HAND 8(4): 410-416, 2013.
Nydick JA, Olliff BW, Garcia MJ, et al.: A Comparison of percutaneous needle fasciotomy and collagenase
injection for Dupuytren disease. J Hand Surg Am 38(12): 2377-2380, 2013.
Peimer CA, Blazar P, Coleman S, et al.: Dupuytren contracture recurrence following treatment with
collagenase Clostridium histolyticum (CORDLESS study): 3-year data. J Hand Surg Am 38(1): 12-22, 2013.
Peimer CA, McGoldrick CA, Fiore GJ: Nonsurgical treatment of Dupuytren contracture: 1-year US post-
marketing safety data for collagenase Clostridium histolyticum. Hand 7: 143-146, 2012.
Pess GM, Gelb RI, Tien RI, et al.: Effect of delayed finger extension on the efficacy and safety of collagenase
Clostridium histolyticum treatment for Dupuytren contracture. Abstract, Presented at the 69th Annual Meeting
of the ASSH September 18-20, 2014, Boston, MD, 2014.
Rayan GM: Dupuytren disease: anatomy, pathology, presentation, and treatment. J Bone Joint Surg Am 89:
189-198, 2007.
Scherman P, Jenmalm P, Dahlin LB: Early outcome of needle fasciotomy and collagenase injection in
treatment of Dupuytren contracture: a 2-center prospective randomized clinical trial. Abstract, Presented at
the 69th Annual Meeting of the ASSH, September 18-20, 2014, Boston, MD 2014.
Starkweather KD, Lattuga S, Hurst LC, et al.: Collagenase in the treatment of Dupuytren disease: an in vitro
study. J Hand Surg Am 21: 490-495, 1996.
Van Rijssen AL, Gerbrandy FS, Ter Linden H, et al.: A comparison of the direct outcomes of percutaneous
needle fasciotomy and limited fasciectomy for Dupuytren's disease: a 6-week-follow-up study. J Hand Surg
Am 31(5): 717-725, 2006.
Watt A, Curtin C, Hentz V: Collagenase injection as nonsurgical treatment of Dupuytren disease: 8-year
follow-up. J Hand Surg Am 35(4): 534-539, 2010.
Witthaut J, Jones G, Skrepnik N, et al.: Efficacy and safety of collagenase Clostridium histolyticum injection
for Dupuytren contracture: short-term results from 2 open-label studies. J Hand Surg Am 38: 2-11, 2013.
XIAFLEX Prescribing Information, 2013.

Chapter 29
Surgical Handling and Local Flap Coverage for Distal
Amputations, Skin Loss, and Nail Bed Injuries
Raymond A. Wittstadt
Helen G. Hui-Chou
INDICATIONS
Tissue loss and amputations of the fingers are among the most common injuries encountered in the
emergency room. A 1982 survey of emergency departments across the United States by the National
Institute for Occupational Safety and Health found that 25.7% of its workload was caused by occupational
digit injuries. These injuries have considerable social and economic impact and can lead to prolonged lost
time from work. Unfortunately, treatment of these injuries is often relegated to the least skilled or
experienced providers. We believe that careful consideration and discussion of the treatment options can
improve functional outcomes and minimize lost time from work.
By convention, the fingertip is that portion of the finger distal to the distal interphalangeal (DIP) joint and
tendon insertions. It is a complex anatomic area with almost all appendicular tissue types represented and
vulnerable to injury. The volar pulp consists of highly innervated glabrous skin and subcutaneous fat
anchored by fibrous septa. The dorsal surface perionychium contains the nail plate; nail bed, with sterile
and germinal matrix; and specialized eponychium, paronychium, and hyponychium (Fig. 29-1).
Goals of treatment in fingertip injuries include preservation of adequate sensation while minimizing neuroma
tenderness, provision of durable skin coverage, prevention of proximal joint contractures, early return to
work, and maximum finger length consistent with the above.
Many techniques have been utilized over the years to address injuries and tissue loss in the fingertip. There
is no one best way to handle every injury and treatment must be individualized. Each injury may have
several solutions. The hand surgeon must fully evaluate each patient's occupation, hobbies, circumstances
surrounding the injury, and emotional attitude regarding treatment options. Frank discussion of recovery
times for the various treatment options along with expected outcomes usually results in a mutually
agreeable solution.
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FIGURE 29-1 Fingertip anatomy. Note that the germinal and sterile matrix rest directly on the dorsal
periosteum of the distal phalanx. Numerous fibrous septa anchor volar glabrous skin to the underlying bone.
Indications for replantation of a digit at the distal phalanx level are still controversial. Some indications
include amputation proximal to the lunula, since no other procedure can salvage the nail. Replantation may
be valuable for musicians, business people, and others exposed to the public in their occupations or for
those requiring specialized use of the fingertip. A strong indication exists for children because of social and
psychological implications. Lastly, the surgeon must consider the patient's age, presence of systemic
disease, level and type of amputation, and patient motivation before replantation is selected. Replantation
can avoid a resulting painful stump when compared to revision amputation (1). However, some
considerations of replantation outcome must be addressed. Hattori found that aesthetic appearance may be
unsatisfactory due to pulp atrophy and nail deformity. Recovery of sensation may be decreased with only
recovery of protective sensation. The average total cost of successful replantation was five times more than
the cost of amputation and closure. Replant patients had a longer hospital stay and longer time off work (2).
Replantation of the distal part has been shown by Wang et al. to have longer return to work, inferior
sensation, and active range of motion. Replantation may be considered only after careful discussion with
each patient regarding quality of life (3).
Causes of fingertip injuries fall into three main categories: crush, laceration, and avulsion. Crushing is
caused by the application of pressure to the fingertip, crushing the structures or pinching with enough force
to cause amputation. Catching the fingertip in a machine or door is typical of this mechanism. Lacerations
occur with sharp objects such as a knife or saw. Laceration is a common component of essentially all open
distal tip injuries. The amount of tissue trauma, contamination, and orientation of the laceration or tissue
loss will significantly influence the reconstructive options. Avulsion occurs when tissue is removed by
tangentially applied forces or distraction. Machine “roller injuries” are typical examples of avulsion trauma.
This mechanism of injury, with its traction force, may present a greater zone of injury than is initially
apparent due to more proximal damage to vessels and nerves.
Cleanly amputated fingertips at or proximal to the DIP joint can be considered for replantation. Crushed or
avulsed tissue is rarely suitable for replantation but can occasionally be used as a skin graft or composite
graft when multiple digits have been traumatized.
CONTRAINDICATIONS
Absolute contraindications to any one technique cannot be given. However, some relative contraindications
should be considered. Rotation or advancement flaps should be used with caution, or not at all, in patients with
vascular disorders such as Raynaud's disease, renal failure, some connective tissue disorders, or inflammatory
arthropathies. Coverage alternatives that require an extreme flexed posture or lengthy immobilization must be
weighed against potential joint contractures. Heroic efforts to salvage nearly unreconstructible injuries with
multistep operative plans requiring complex tissue transfers must be balanced against ultimate functional and
cosmetic concerns.
Operative planning begins with the patient's presentation in the emergency room. It is appropriate to perform and
document an evaluation of the entire patient, particularly health status related to diabetes, vascular disease, and
smoking. An expanded history should include mechanism and time of injury, whether the hand was caught in a
machine, and if so, for how long, appropriate past medical and hand injury history, medications, and allergies.
Hand dominance, occupation, and
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nonoccupational activities should be noted as well. Tetanus status should be determined and not overlooked.
Examination requires complete careful removal of all dressings. This can be painful, but sensation in the injured
area must be determined before any local anesthesia is administered. Once sensation has been evaluated and
documented (two-point discrimination may be the most available and logical objective data to record), local
anesthesia can be given to provide relief and facilitate further evaluation of the injury. Examination of amputated
tissue, if available, should also be performed. Factors such as angle of tissue loss, function of adjacent joints
and tendons, nail involvement, and amount of exposed bone should be noted.
Standard x-ray views are mandatory for all fingertip injuries. The amputated tissue should also be imaged in
cases in which replantation or use of the amputated part for graft purposes is contemplated. Because a crushing
mechanism is the cause of many distal tip injuries, it is important to check for fracture lines that may extend
proximally into the joint and evaluate the degree of comminution of the involved segment. The bony injury often
limits or influences the ultimate treatment choice.
Some consideration should be given to the venue and circumstances in which many of these procedures are
performed. As noted previously, care for tip injuries should not be assigned to trainees or less experienced
physicians. The permanency and importance of the results requires greater attention and involvement by the
attending hand surgeon. Many of these procedures can be safely, effectively, and efficiently performed in a well-
stocked and staffed emergency department. Appropriate equipment, lighting, anesthetic capability, and
manpower are all important variables that determine whether this is feasible. It is never wrong to take a distal tip
injury to a formal operating room, especially when multiple digits are involved or the flexor side is significantly
traumatized. If there is any doubt about the level of care that can be rendered in a particular venue, then
defaulting to the safest, most controlled environment will yield optimal results.
Unless there are exposed joint surfaces, tendons, or neurovascular structures, definitive treatment can usually
be delayed by initial mechanical debridement and irrigation, followed by the application of Xeroform Petrolatum
dressing (Sherwood Medical, St. Louis, MO) or similar ointment dressing. There may be a benefit to delaying
definitive treatment to assess the viability of traumatized tissue. In many cases, amputation may be the favored
treatment after an initial assessment. However, if the digit is cleaned and dressed in the emergency department,
later evaluation by the surgeon, consideration by the patient, and the “test of viability” afforded by reflection of 24
to 72 hours may alter the decision in favor of a reconstructive option over ablation.
Although this chapter focuses on local flaps for fingertip coverage, all techniques should be considered. Factors
influencing the choice of techniques include the angle of tissue loss, amount of exposed bone, condition of the
amputated part (if available), injuries to adjacent fingers, digit involved, size and location of defect, and patient
wishes. Treatment principles should include preservation of all viable tissue and utilization of amputated parts. In
general, it is best to choose the simplest procedure consistent with individual factors and goals of treatment.
A reconstructive ladder is a consistent image to maintain when considering the options available to treat distal tip
amputation. The steps up the ladder reflect increasing complexity of the reconstructive effort. The range of
treatment alternatives includes healing by secondary intention, shortening and primary closure, skin grafting
(split or full thickness), replacement of the amputated part with microsurgical techniques or a nonvascularized
composite graft, or flap reconstruction. Flaps that are attractive and useful for treating fingertip injuries include
local, regional, or distant flaps.
TECHNIQUES
Nail Bed Injuries
Nail bed injuries may involve underlying distal phalanx fractures. Subungual hematomas may indicate extent of
underlying involvement. Traditionally, hematomas larger than 50% of the nail bed surface were thought to
require nail plate removal and formal repair. However, recent studies have called this into question. Recent
studies have modified current operative management of nail bed injuries. Seaberg et al. looked at 45 children
with fingertip injuries. Over half of the children had subungual hematomas greater than 50% of the nail bed
surface area and 30% had fractures (4). All were treated with trephination alone. Follow-up at 10 months
revealed no complications. Performing randomized trials for this injury is difficult, but Gellman (5) did a
prospective study of 53 patients, ages 1 year to 20 years old, with 26 consecutive patients receiving formal
repair and 27 undergoing trephination or no treatment. One-third of cases had subungual hematomas greater
than 75% of the nail. There was no difference in outcomes at 2-year follow-up. However, the cost of nonsurgical
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treatment averaged $283, while nail bed repair costs averaged $1,263. Costello and Howes (6) found no
evidence to support the use of routine antibiotics for subungual hematomas.
Formal nail bed repair is still appropriate in patients with displaced fractures of the distal phalanx or injury to
other portions of the dorsal fingertip. Repair of lacerated paronychium, eponychium, or hyponychium should be
done with fine absorbable suture such as 6-0 or 7-0 chromic. Strauss et al. have found that nail bed repair with
2-octylcyanoacrylate (Dermabond) had similar cosmetic and functional results and was faster than suture repair
(7,8). Nail plate removal to accomplish this is often needed and the removed nail plate or other material, such as
a suture pack foil, should be placed under the eponychial fold to minimize scar formation between the fold and
the germinal matrix. The foil or nail plate should be trephined centrally prior to replacement and can be sutured in
place as necessary with absorbable suture. We prefer not to use nonadherent gauze for this purpose. If the
amputated or avulsed part is available, it should be carefully inspected for specialized tissue that can be utilized
as a full-thickness skin graft. Loss of eponychium will cause a permanent deformity of the nail fold and effect
subsequent nail plate growth. If the amputated dorsal tissue is not available, careful consideration of how to
reconstruct this area is needed if length is to be maintained. Split-thickness grafting from an adjacent finger (less
common) or toe (more common) can be used, but donor site cosmetic deformity should be discussed with the
patient.
Distal Phalanx Fracture

Many fingertip injuries have associated fractures of the distal phalanx. Frequently, these are minor or minimally
displaced, and even if highly comminuted, they are usually stable due to the fibrous septa of the surrounding
tissue. They do not require specific treatment other than protective splinting. However, significantly displaced or
unstable fractures of the diaphysis or articular surfaces should be stabilized. Utilization of an appropriate gauge
hypodermic needle can be hand drilled across these fractures in the emergency room or operating room,
preferably under mini C-arm guidance, and does not usually need to cross the DIP joint. K-wires or miniscrew
fixation can be used if needed to stabilize large articular fragments. Fingertip injuries with accompanying
fractures can have prolonged recovery times. DaCruz et al. (9) found that 6 months postinjury, only 17% of
patients with tuft fractures had fully recovered, with many patients experiencing some residual numbness, cold
sensitivity, or hyperesthesia.
Epiphyseal fractures of the distal phalanx require special consideration, especially in children. Seymour's fracture
is an extra-articular transverse fracture of the base of the distal phalanx. Prior to closure of the epiphysis, this
fracture will clinically mimic mallet deformities as the terminal extensor tendon inserts into the epiphysis only,
although the fracture does not involve the DIP joint articular surface. The fracture is usually open and is prone to
infection unless debrided. Other problems associated with Seymour's fracture include incomplete reduction due
to interposition of a bucket-handle flap of nailfold skin, fracture instability after removal of the nail plate,
premature closure of the epiphysis, and dorsal rotation of the epiphysis. Al-Qattan (10) also noted that this
fracture can also occur in adults. These fractures can be treated by closed reduction and splint or open
reduction and K-wire fixation.
Healing by Secondary Intention

Open treatment, or healing by secondary intention, results in healing by the re-epithelialization of granulation
tissue and wound contracture. It is most useful in children and for defects of modest size (1 to 1.5 cm or less) or
tangential injuries with variable levels of tissue loss. This treatment is simple to perform and “burns no bridges”
because any reconstructive option can still be elected after an initial period of observation. It arguably provides
the best sensation, and healing time is comparable to that of other methods. Complications are rare, including an
almost nonexistent infection rate, but stump tenderness can occur and cold intolerance is common with all types
of finger trauma. Like all tip injuries in which the distal phalanx is involved, if there is any unsupported nail bed, a
hook nail deformity may result.
Primary Closure with Digital Shortening

Primary closure, when possible, is simple and provides good sensation, rapid healing, and early mobilization.
The nail bed should be trimmed to the level of the bony injury and should not be relied upon to cover exposed
bone, which inevitably leads to hook nail deformities. Bone should be trimmed to achieve a tension-free closure
and insure adequate soft-tissue padding over the bone. Preservation of tendon insertions is helpful to maintain
motion and strength. Care should be taken to prevent excessive stump tenderness by trimming nerve ends at
least 1 cm proximal to the level of the bony injury.
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Skin Grafting
Although favored by some surgeons involved in care of the hand, skin grafting is rarely used at our institution for
reconstruction. It is inferior in the key parameters that are of greatest consideration in this common injury.
Skin grafts are associated with lack of durability, diminished sensibility, hyperpigmentation, asymmetric
contraction, and potential donor morbidity. Almost any of the other options discussed will yield superior results to
even a well-performed skin grafting procedure.
However, split- or full-thickness skin grafts can be used to cover defects considered too large to heal by
secondary intention or those not felt to be candidates for the other coverage alternatives. Survival of a skin graft
requires that the area on which it is placed has sufficient blood supply to support the transplanted skin. Exposed
bone, cartilage, or tendon typically does not meet this requirement.
Skin texture and color match should be considered. When possible, glabrous skin from the hypothenar area or
foot should be used. If primary closure of the donor site is not possible, it too can be skin grafted. If nonglabrous
skin is used, avoid donor areas that are hair bearing. Glabrous skin from the amputated part, if available and not
too damaged, can be used as well. When glabrous skin is used, the appearance can be quite satisfactory, but
sensation is inferior to healing by secondary intention or primary closure.
Composite Grafting
Replacement of the amputated part as a nonvascularized composite graft works best in children younger than 2
years of age. Results become increasingly unpredictable as the child approaches 8 and this appealing technique
has little chance of success in older children or adults. Graft failure may delay recovery, but the tissue often
serves as a biologic dressing as the tip reepithelializes. Microvascular replantation at this level may provide the
best appearance, but it is technically demanding. Nerve recovery and sensation are variable after replantation,
and decreased joint motion may limit functional recovery.
Regional flaps that will not reach to the fingertip, distant random flaps, and microvascular free flaps will not be
discussed further, but they should be considered when appropriate.
Local Flaps for Fingertip Coverage

By definition, a flap consists of skin with varying amount of underlying tissue. Unlike skin grafts, this tissue
receives its blood supply from a source other than the tissue on which it is placed. Flaps that receive their blood
supply from many minute vessels in the subdermal or subcutaneous plexus are termed “random” flaps. Flaps that
receive blood via a single vessel are termed “axial.” Local flaps available for fingertip coverage include both
types. Flaps are also classified as homodigital, from the same digit, or heterodigital, from an adjacent digit.
Reconstruction with flaps may be done as a single-staged or multiple-staged procedure.
Digital tip amputations with exposed bone can be treated by several methods already described, but local flaps
are attractive because of their proximity, tissue match, possibility of enhanced function, sensibility, and
acceptable complication profile. Typically, if bone length has been preserved, then the use of local flaps is
appropriate. Flaps to be discussed in detail include volar V-Y advancement, lateral V-Y advancement, volar flap
advancement, thenar flap, cross-finger flap, and homodigital island flap.
Volar V-Y Advancement Flap The volar V-Y advancement flap was first described in 1970 by Atasoy and
Kleinert for most tip amputations with exposed bone, especially transverse or dorsal oblique amputations. Volar
oblique amputations may not have adequate skin for this technique. As a general rule, in order to be a candidate
for a V-Y advancement, 50% of the skin of the distal tip must remain, as measured by assessing the distance
between the proximal most aspect of the wound and the DIP joint flexion crease.
This procedure can be done in the emergency room setting if all of the necessary equipment is available. Digital
block anesthesia is used; we prefer Marcaine 0.5% administered via a single midline injection into the
subcutaneous tissue at the base of the finger. While use of local anesthesia with epinephrine is increasingly
popular, its use in this type of procedure may limit assessment of flap vascularity.
The size of the defect at the tip is measured or a pattern from the inner sterile glove wrapping is made. This is
then transferred to the volar distal pulp that is to be advanced. A distally based triangle is drawn around the
pattern. The apex of the triangle should be at the DIP joint flexion crease
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(Fig. 29-2). The skin is incised. Blunt dissection with sharp scissors is done to isolate the radial and ulnar digital
neurovascular bundles (Fig. 29-3). All subcutaneous tissue except the bundles must be divided to allow tissue
advancement. The deep fibrous septa between the flap and the underlying distal phalanx must be cut as well.
This should free up the flap completely so that only the bundles remain as attachments (Fig. 29-4). At this point,
the Penrose tourniquet is released to check flap viability.
An alternative to raising the flap is to first mobilize the deep portion from the distal phalanx and flexor sheath by
dividing the fibrous septa. The importance of this step, regardless of ultimate technique, cannot be overstated.
By then controlling the injured edge of the volar skin with two skin hooks and providing longitudinal traction,
sharp dissection of the skin and underlying tissue mobilizes the flap. In this version, the terminal branches of the
nerve and vessel are not directly isolated or even visualized consistently. The contact of the knife blade to the
fibrous tissue under tension must be trusted to divide the correct tissue and spare the other vital structures. The
more experienced the surgeon becomes at raising this flap, the more appealing this option may present, as it
may limit further flap trauma caused by excessive spreading or skeletonizing the neurovascular bundles.
FIGURE 29-2 Volar V-Y flap. Preoperative outline of the skin incision used to create a volar skin flap in
preparation for distal advancement. The tip of the V incision should be at the DIP joint flexion crease.
FIGURE 29-3 Volar V-Y flap. Skin and subcutaneous tissue have been incised. Great care must be taken to
avoid injury to the radial and ulnar neurovascular bundles. Fibrous septa between the flap and the underlying
bone must be carefully cut to permit distal translation of the flap.
FIGURE 29-4 Volar V-Y flap. The flap has been mobilized and reflected proximally. Placement of stay sutures at
the distal corners of the flap allows manipulation without the use of forceps that can traumatize the flap.
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FIGURE 29-5 Volar V-Y flap. The flap has been advanced distally to cover the tip defect. The resultant defect
has been closed, converting the V defect to a Y.
The flap is then carefully advanced distally and the wide base of the triangle is sutured to the remaining nail bed.
I prefer 4-0 or 5-0 chromic suture. Care should be taken that the nail bed has adequate bony support to prevent
hook nail deformities. Some defatting of the skin adjacent to the flap may be helpful for a tension-free closure.
Defatting of the flap itself is risky and usually not needed. The proximal V defect left by flap advancement is
closed, converting the V to a Y in the usual fashion (Fig. 29-5).
A sterile dressing with a petroleum gauze strip, dry gauze, or eye pad, followed by tube gauze or other overwrap,
is applied. Coban (3M) or other compressive wrapping should be avoided. Splinting is not usually necessary.
Early active motion is encouraged. Initial follow-up is at 3 to 5 days. Subsequent dressings should be used to
protect the sutures until removed or dissolved.
Outcomes have been generally favorable with one report noting normal sensibility and motion in 91% of 61
patients, but other investigators have noted hypesthesia, dysesthesia, hypersensitivity, or cold intolerance in
57% to 70% of cases. A recent study suggested that sensation may be related to the amount of advancement.
Advancements of 1 cm or less have the best sensation, while advancement beyond 1.5 cm had more
dysesthesia and diminished sensation.
Lateral V-Y Advancement Flaps Kutler is credited with the first description of the bilateral lateral V-Y flaps for
fingertip coverage. He described two lateral triangular flaps, again based on the neurovascular pedicles, which
are advanced over the fingertip. This is theoretically most useful in palmar oblique and transverse tip
amputations. This procedure is less commonly utilized as it requires more dissection, has only one vessel in
each flap, and may denervate portions of the eponychial fold dorsal to the raised flaps. This has the potential for
increased scarring and limits its appeal compared with more robust alternatives.
Preparation of the digit, anesthesia, and tourniquet use is as described previously. Two distally based triangular
flaps are drawn out on the lateral sides of the finger. The apex is proximal and can extend to the DIP flexion
crease (Fig. 29-6). The skin is carefully incised and blunt dissection is used to identify the neurovascular bundle,
which will be entering on the volar side of the triangular flap at the midlateral line. The full thickness of the flap is
elevated off the underlying bone. The flaps are completely freed up on their pedicles (Fig. 29-7). The tourniquet
is released, flap vascularity is checked, and the flaps are advanced distally and sutured to each other in the
midline. Suturing to the nail bed and remaining volar skin is continued. Again, defatting of the skin volar to the
flap may help with a tension-free closure. The proximal apex of the triangle is closed converting
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the V to a Y (Fig. 29-8). Care must be taken to avoid strangulating the tenuous pedicle to this fragile flap.
Postoperative care is similar to that of the previously described volar flap. Outcomes are similar to the volar flap.
FIGURE 29-6 Lateral V flaps have been created. The proximal tip of the V is at the DIP flexion crease. Flaps
have been raised, preserving the neurovascular bundles. Careful division of the underlying fibrous septa is
necessary to allow flap advancement.
FIGURE 29-7 Lateral V-Y flaps. Complete separation of flaps from the underlying distal phalanx and proximal
extent of the flaps.
FIGURE 29-8 Lateral V-Y flaps. Flaps have been sutured together in the midline covering the defect. The
resultant defect is closed primarily, converting the V defect to a Y incision.
Lateral Triangular Flap The lateral triangular flap was described by Venkataswami and Subramanian (11) and
provides more tissue and potentially more distal advancement. This laterally based triangular flap is most useful
for radial or ulnar oblique amputations. The sides of the flap typically measure 2 to 2.5 times the base width and
can extend up to the PIP joint level. Advancement is typically in the 1.5-cm range with further advancement
increasing the risk of dysesthesia and worsening sensory recovery.
Homodigital Flaps
Various patterns have been designed for homodigital flaps from the same digit. These are axial pattern flaps
based typically on a single neurovascular bundle, although bipedicled flaps have been described as well. The
flaps can be based on its blood supply in an anterograde/direct or retrograde/reverse fashion. The advantages
of homodigital flaps are single-stage reconstruction that provides immediate sensate glabrous skin with injury
and donor site isolated to a single digit. Flaps have been described with various designs and donor sites, with
sizes ranging 2 to 4 cm. The complications with homodigital axial flaps include flexion contracture, nail deformity,
and flap necrosis. These flaps are contraindicated in patient with peripheral vascular disease.
Moberg Volar Advancement Flap Moberg is generally credited with the technique of advancement of the entire
volar skin for coverage of the fingertip. The Moberg Volar Advancement Flap creates a flap of the entire volar
skin based on two neurovascular pedicles that can provide sensate skin and subcutaneous tissue for tip
amputations. Although more commonly applied to the thumb because of its more mobile skin, consistent separate
dorsal skin blood supply, and less tendency for flexion contractures, it has been utilized in all fingers.
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Extreme caution should be exercised in using the Moberg concept in the triphalangeal fingers. This is primarily
due to the fact that the thumb alone has a generous dorsal blood supply that is largely independent of the more
central, volar digital vessels. The remaining fingers do not have this anatomic benefit, so the Moberg flap
technique may jeopardize the viability of the dorsal skin. Although not well reported, no other center has been
able to duplicate Moberg's results with the volar advancement flap when used in digits other than the thumb.
This basic anatomic difference is the likely reason for the inferior results and higher complication rates
accompanying this type of tissue mobilization in the fingers.
This procedure should be performed in the operating room after discussing all options with the patient. Regional
or general anesthesia is used, the limb is exsanguinated, and the tourniquet is inflated. Midaxial incisions are
outlined on both sides of the involved digit (Fig. 29-9). The incisions are deepened with care. Sharp and blunt
dissection is used to completely separate the volar skin from the flexor tendon sheath (Fig. 29-10). Injury to the
neurovascular bundles must be avoided. Particularly in the fingers, care must be taken to protect the takeoff of
the dorsal branch of the sensory nerve.
Sectioning of the skin at the base of the flap while preserving the neurovascular bundles may aid providing
additional advancement. One report noted that an additional 0.5 to 1.0 cm of advancement can be obtained. The
defect created is skin grafted. The entire flap is advanced flexing the thumb IP
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joint if needed. The distal tip of the flap can be contoured to fit the defect as necessary. A postoperative dressing
is applied, incorporating a dorsal extension block-type splint. Flap viability is checked in 3 to 5 days with
continuation of the dorsal splint for 2 weeks. Therapy is then started to promote range of motion (Fig. 29-11).
FIGURE 29-9 Moberg flap. Preoperative midlateral incision was utilized on both the radial and ulnar sides of the
thumb.
FIGURE 29-10 Moberg flap. An entire volar skin flap has been raised. The skin flap includes both neurovascular
bundles. Flexor tendon sheath should not be injured or incised.
FIGURE 29-11 Moberg flap. The flap has been advanced distally to cover the defect and sutured in place. Note
the slight flexion of the interphalangeal joint.
Hueston Flap/Spiral Flap Hueston first described the Hueston or spiral flap in 1966, as a single-stage flap that
uses volar skin of the digit to provide coverage of the fingertip with skin of normal thickness and similar tactile
sensory pattern. It is useful for distal guillotine or large pulp defects from volar oblique amputations. This flap is
elevated with an incision down the midaxial line of the ulnar side of the digit. The flap is based on one
neurovascular bundle in an anterograde fashion. The incision then turns across the volar aspect to reach the
proximal interphalangeal joint crease, to allow coverage of a distal amputation wound. This allows for a spiral
advancement of the volar glabrous skin. The flap is raised anterior to the first neurovascular bundle, but the
dissection is then made dorsal to the bundle at its base. The distal flap is advanced and sutured to restore pulp
shape and contour. A full-thickness skin graft closes the proximal donor skin defect (12). This flap allows sensory
two-point discrimination of 4 mm, minimal cold intolerance, or hypersensitivity, with a good aesthetic and
functional outcome.
Homodigital Island Flap The island flap is another homodigital flap that utilizes anterograde flow, but the
neurovascular bundle is dissected free and the donor skin is circumferentially freed and becomes a distinct
island on the pedicle (13,14,15). This distal island flap advancement is possible because of freeing of soft
tissues around the pedicle, the natural slight elasticity of the pedicle, and slight metacarpophalangeal or
interphalangeal flexion, if necessary.
The procedure is performed under tourniquet after exsanguination. After thorough debridement, the dimensions
of the defect are measured. A flap is designed with the measured dimensions and drawn over either the distal
ulnar or radial aspect of the finger centered over the neurovascular bundle (Fig. 29-12).
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The flap is not incised until the neurovascular bundle has been dissected, to allow adjustments in orientation of
the island flap over the pedicle. A midlateral incision is then made proximal to the outline flap. The neurovascular
bundle is dissected free of surrounding tissue in a circumferential fashion. This involves completely releasing the
pedicle from tethering structures, including Cleland's and Grayson ligaments as well as arterial side branches.
The artery and nerve are kept together, and after isolation of the neurovascular bundle, it is traced distally to the
marked island flap. Once the island flap is confirmed centered over the neurovascular pedicle, the flap can be
incised and dissected down to the flexor tendon sheath (Fig. 29-13). Slight interphalangeal joint flexion facilitates
advancement of the flap into the defect. The flap is inset using 5-0 chromic suture. A full-thickness skin graft is
used to cover the small donor defect. Results are good with this single-stage procedure, with two-point
discrimination of 3 to 7 mm reported and minimal to no flexion contracture (Fig. 29-14).
FIGURE 29-12 Volar fingertip defect with a homodigital island flap designed to be based off the ulnar digital
neurovascular bundle.
Various donor sites have been described based on the homodigital island flap pedicle concept (16). One can
utilize more lateral and dorsal skin as the donor site. This is called the oblique dorsal transpositional flap and is
an anterograde homodigital island flap based on a single neurovascular bundle. The flaps are designed on either
the ulnar-dorsal or radial-dorsal side of the injured digit. Sizes of defects covered range from 1.7 × 1.2 cm to 3.8
× 1.7 cm. In this series, 2-PD was 5 to 9 mm.
FIGURE 29-13 Homodigital island flap raised based on the ulnar digital neurovascular bundle.
FIGURE 29-14 Final inset of the homodigital island flap onto the volar tip defect with a fullthickness skin graft to
reconstruct the donor site.
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Pivot Flap Ni et al. (17) described a palmar pivot flap to repair fingertip and pulp defects no greater than 1.5 cm
in length. This variation of the anterograde homodigital island flap is designed to allow pivot of a donor island
flap no greater than the width of the volar aspect of the digit. The flap is based on one neurovascular bundle,
either radial or ulnar, and the flap is dissected down to subcutaneous tissue over the contralateral pedicle. The
transverse portion of the flap is then dissected off the flexor tendon sheath. At the ipsilateral pedicle, the
dissection included the neurovascular bundle with the flap and proceeded proximally into the finger releasing
attachments to Cleland and Grayson ligaments. The elevated flap is then pivoted 90 degrees on the
neurovascular bundle so that the pedicled lateral border is sutured to the proximal wound margin. A small full-
thickness skin graft is required to resurface the donor site defect over the contralateral pedicle. Flap size ranged
from 1.8 × 1.5 cm to 2.6 × 2.2 cm. The sensibility recovered demonstrated 2-PD from 3 to 6 mm. There were no
hook nail deformities and minimal DIP and PIP joint contractures.
Retrograde/Reverse Homodigital Island Flap Retrograde or reverse homodigital island flaps have also been
described for reconstruction of fingertip and pulp defects with the advantage of avoiding residual joint stiffness or
contractures sometimes seen with anterograde/direct flaps (18,19,20,21). Island flaps are designed from proximal
volar skin based on a single neurovascular bundle. This allows for a wide arc of rotation, which can easily cover
distal defects both volar and dorsal. Care must be taken to avoid dissection beyond the distal transverse digital
artery. Retrograde flap sizes may be larger, up to 3.0 × 2.7 cm.
The wound is initially debrided and size and shape measured. The flap is designed along the midlateral axis of
the proximal phalanx. Proximal identification of neurovascular bundle is made and dissection carried out in a
proximal to distal direction. The artery may be harvested with or without the digital nerve. A generous cuff of
subcutaneous tissue around the vascular pedicle is preserved to allow for adequate venous drainage. Dissection
is never carried out beyond 3 to 5 mm proximal to the DIP joint, as this corresponds to the distal transverse
digital artery. The flap is rotated and sutured into the defect with 5-0 nylon. The donor site defect may be closed
primarily, if small and tension-free, or a small full-thickness skin graft applied. This flap can also be designed
from proximal dorsal skin in a similar retrograde fashion (22).
Complications of the reverse homodigital island flap include high flap loss rate, decreased sensation, and the
sacrifice of one digital neurovascular bundle (23). Two-point discrimination testing yields a range from 6.0 to 8.8
mm. Patients reported hypersensitivity and cold intolerance of their treated finger. However, all patients had full
range of motion.
When comparing anterograde with retrograde homodigital island flaps, Braga-Silva et al. (24) found that
interphalangeal joint mobility and sensory discrimination were the significant differences. Losses of 10 to 15
degrees were seen in the anterograde/direct flap group in the PIP joint and 10 degrees in the DIP joint. However,
sensory recovery was superior in the anterograde/direct flap group over the retrograde/reverse flap group, even
when nerve suture repair was performed with the retrograde/reverse homodigital island flaps.
The overall benefits of homodigital axial flaps are to provide one-stage reconstruction with wellmatched glabrous
and ideally sensate skin from the same injured digit. However, these flaps take considerably more time and
microsurgical magnification. There are complications inherent with these flaps such as flap loss, joint stiffness,
and decreased sensory recovery that need to be considered when choosing this reconstructive option.
Thenar Flap When skin loss is mostly volar on the index and middle fingers, a thenar flap can be considered.
This is indicated in younger individuals (age less than 35) with no arthritis or trauma involving the finger joints.
Use in the ring and small fingers is generally contraindicated because of the excessive opposition required of the
thumb ray.
The thenar flap was first described in 1926 and has undergone subsequent modifications by Flatt, Smith, Albin,
and others. This flap is indicated for amputation involving oblique volar tissue loss when length preservation is
important. The potential for joint stiffness and palmar scarring needs to be discussed with the patient, or more
often the parents, as this flap is commonly utilized in children.
This procedure should be done in the formal operating room under regional or general anesthesia. The size of
the defect is measured, as the flap should be approximately 20% larger in both length and width. The flap is
usually proximally based, but it can be radially or ulnarly based depending on the orientation of the defect (Fig.
29-15). The flap should be located over the volar aspect of the thumb at the level of the MP joint. Flaps that are
based too low over the thenar eminence tend to have more painful scars. The flap should be elevated along the
underlying subcutaneous tissue (Fig. 29-16). Care must be taken to protect the neurovascular bundle to the
thumb. The donor defect can often be closed primarily or can be skin grafted (Figs. 29-17 and 29-18).
Smith and Albin described the thenar “H-flap” for more transverse amputations. The donor defect is closed at the
time of flap sectioning between 2 and 3 weeks later. This can often be done under local anesthesia, age
permitting, again usually in the operating room. Some contouring of the flap is often necessary at the time of
sectioning. Postoperative therapy to regain finger motion is usually recommended as needed.
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FIGURE 29-15 Thenar flap. The defect is on the flexed index finger, with outline of the thenar flap to cover the
tip.
FIGURE 29-16 Thenar flap. The flap has been raised. The skin has full-thickness subcutaneous tissue elevated
off deep fascia. Care must be taken not to injure the thenar neurovascular bundles or flexor tendon sheath.
FIGURE 29-17 Thenar flap. A defect created by elevation of the thenar flap can usually be closed primarily, as
shown here. Alternatively, a full-thickness skin graft can be applied to close the defect.
FIGURE 29-18 Thenar flap. The flap has been sutured in position to cover the defect. Note the amount of finger
flexion.
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Patients older than 30 years of age have a higher risk of joint stiffness, as do patients with any type of
connective tissue disorder, arthritis, or adjacent finger injury requiring early motion. Flap loss is uncommon, as is
traumatic premature separation of the flap. Pinning of the joints to help maintain the position of the finger is
contraindicated.
Cross-Finger Flap The cross-finger flap technique was initially described in 1950. This flap is useful when
length needs to be maintained and the tissue loss is mostly volar. Careful consideration of its use is necessary
because an adjacent finger provides the donor tissue and the skin-grafted defect is on the dorsum of the finger.
Curtis was an early advocate of this flap and reported on its advantages.
This procedure is done under regional or general anesthesia. The size of the defect is transferred to the dorsum
of the finger over the middle phalanx (Fig. 29-19). The flap is based on the side closest to the injured finger. In
general, the flap is made about 2 mm larger on its three sides. Usually, the far edge of the flap should be at or
dorsal to the midlateral line. The proximal and distal extent of the flap should not extend beyond the midlines of
the DIP or PIP joints, but taking the flap to these levels is almost always the best option, because undersizing the
donor is a critical issue that must be avoided.
The flap is carefully incised on the three sides and elevated gently (Fig. 29-20). Traction sutures placed at the
corners can help minimize the use of forceps on the edges of the flap. The skin and
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subcutaneous tissue are elevated off the paratenon of the extensor tendon. As the flap depends on the
subdermal plexus for its blood supply, care must be taken to prevent cutting into the subcutaneous tissue at the
lateral base of the flap. The flap is reflected and the tourniquet is released to check the flap's vascularity. The
flap is then sutured in place on the injured finger. A full-thickness skin graft is then usually harvested from the
groin or inner upper arm to cover the donor defect on the dorsum of the finger (Fig. 29-21). The graft should be
large enough to cover the portion of
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the flap between the two fingers. This is important to prevent desiccation of the base of the flap. Generally,
suture repair and careful dressing of the flap are sufficient to maintain the position of the joined fingers. Avoid the
temptation to pin the digits in the associated position; the chances of injuring the bundle and pin-associated
complications are simply too great. A soft bulky dressing incorporating a plaster splint is applied. I generally
change the dressing at 1 week to check both the skin graft and the flap. The flap is divided at 2 to 3 weeks in the
operating room. This can be done under local anesthesia if preferred and tolerated by the patient. Both the flap
and the skin-grafted area will need to be contoured, trimmed, and inset (Fig. 29-22). Hand therapy is
recommended to facilitate the recovery of finger motion. Protective sensation returns in about 6 months. Two-
point discrimination of 5 to 10 mm can be expected in 1 to 2 years. Careful inclusion of a dorsal sensory nerve
near the proximal volar aspect of the flap can improve those results (Figs. 29-23 and 29-24).
FIGURE 29-19 Cross-finger flap. A volar soft-tissue defect with no bone loss. The dorsal nail is uninjured.
FIGURE 29-20 Cross-finger flap. Dorsal view of a cross-finger flap raised to cover a volar defect on an adjacent
finger. Note the full thickness of tissue elevated and the preservation of paratenon on the extensor tendon.
FIGURE 29-21 Cross-finger flap. Illustration of the application of a full-thickness skin graft to cover a dorsal
defect on a donor finger and to protect the flap pedicle from desiccation.
FIGURE 29-21 (Continued )
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FIGURE 29-22 Cross-finger flap. Final result after division and inset of the flap.
FIGURE 29-23 An algorithm for fingertip amputation management. (Redrawn from Lemmon JA, Janis JE, Rohrich
RJ: Soft-tissue injuries of the fingertip: methods of evaluation and treatment. An algorithmic approach. Plast
Reconstr Surg 122: 3, 2008.)
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FIGURE 29-24 An algorithm for management of volar oblique fingertip injuries. (Redrawn from Lemmon JA, Janis
JE, Rohrich RJ: Soft-tissue injuries of the fingertip: methods of evaluation and treatment. An algorithmic
approach. Plast Reconstr Surg 122: 3, 2008.)
PEARLS AND PITFALLS

Flap advancement of 12 mm or less results in best sensory recovery. Advancement more than 12 mm causes
significant decrease in sensation to 3.12 Semmes-Weinstein (25).
Use of epinephrine in local anesthetic in distal hand amputations has been shown to be safe with no reported
cases of finger necrosis (26,27).
Release of tourniquet prior to inset is required to ensure blood flow to flaps.
For improved flap advancement, release of pulp septa is necessary.
Design flaps based on defect with appropriate size match to defect, centered over the pedicle if axial in nature.
Children have improved sensory recovery when anterograde homodigital island flaps are used.
Reverse homodigital island flaps have limited sensory recovery when compared with anterograde flaps.
Unsupported nail bed that is allowed to heal by secondary intention can result in hook nail deformity.
POSTOPERATIVE MANAGEMENT AND REHABILITATION

Most patients are seen at 5 to 7 days postoperatively. Those with skin grafts and flaps are seen at 1 week for a
dressing change. Early hand therapy is encouraged to maximize recovery of motion when flap viability is not at
risk.
Time off work is quite variable and difficult to predict. The type of treatment seems to have little effect on return
to work unless a complication, such as flap necrosis or infection, prolongs recovery. Bojsen-Moller found that
recovery was similar for patients treated surgically or conservatively.
In our experience with cross-finger flaps, the final appearance of recipient and donor areas is well accepted and
loss of motion is uncommon. The use of volar, lateral advancement flaps or homodigital axial flaps eliminates the
need for a second procedure, but care must be taken to not try and cover too large a defect. The more tension
that is needed to cover the tip with advancement flaps, the higher the tendency toward hypersensitivity. The
return to heavy manual labor is usually in the range of 4 to 8 weeks in the nonworker's compensation population.
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COMPLICATIONS
Outcome studies on fingertip injuries are complicated by the difficulty in separating results by the injury itself
from those evaluating different types of treatment. Complications include infection, hook nail deformity,
flexion contracture, cold intolerance, altered sensibility, and graft or flap failure. Infection can be minimized
by adequate debridement. Routine use of antibiotics beyond the usual prophylactic recommendation is
usually not indicated. Injuries that occur in a marine or farm environment may need the usual special
considerations regarding antibiotic choice and possible delay in definitive treatment to minimize the potential
for flap loss secondary to infection. Unsupported nail bed that is allowed to heal by secondary intention can
result in hook nail deformity. Trimming the nail bed back to the same level as the bone can prevent hook
nail deformity.
Flexion contractures can be related to the flexed posture of the finger when thenar, Moberg, homodigital
island, or cross-finger flaps are utilized. This needs to be discussed with the patient before surgery. Careful
patient selection is necessary. Use of the thenar, homodigital island, or cross-finger flap in patients older
than 30 to 35 years increases the risk of contractures. DIP joint contractures in the thumb with use of the
Moberg flap are less problematic with little functional loss. Flap division between 2 and 3 weeks along with
early hand therapy helps to minimize this uncommon problem.
Cold intolerance is a common problem, occurring in 30% to 70% of fingertip injuries. While this seems to be
largely related to the injury itself, some authors feel that the incidence is higher in those treated by surgical
methods. Louis, Jebson, and Graham reviewed several follow-up studies and concluded that fingertip
injuries in adults with pulp loss have a 30% to 50% chance of cold intolerance and a 30% chance of altered
sensibility regardless of the technique used. They feel that these problems are a consequence of the injury
and not the treatment.
Altered sensibility also can be a function of either the injury or the treatment. Overstretching the
neurovascular bundles not only risks flap failure due to ischemia but also can increase hypersensitivity at
the fingertip. Sensory recovery is best when wounds are allowed to heal by secondary intention.
Anterograde homodigital island flaps and Moberg flaps tend to have good sensibility, followed by the local
V-Y flaps. Cross-finger flaps do not recover sensation to the same degree as other flaps, but sensation
improves with time.
RESULTS
Although more conservative treatments should always be carefully considered for all fingertip injuries,
skillful use of the flaps discussed here can lead to excellent functional recovery. Transverse amputations
can be treated by many methods. Injuries with oblique tissue loss in which length should be preserved lend
themselves to the various flaps reviewed (Fig. 29-25).
Although no prospective randomized trials have been done, one retrospective review by van den Berg et al.
(28) revealed no significant difference between flap reconstruction, bone shortening, and healing by
secondary intention. Disparities in the literature are due to variations in injuries themselves, when
comparing outcomes such as cold intolerance, nail deformities, aesthetics, and time off from work.
Results specific to each flap are typically good but may reflect the fact that more extensive coverage
procedures are typically chosen for more extensive or complex wounds. Complication rates are low when
experienced surgeons choose reasonable coverage alternatives for appropriate patients and injuries.
Although the cross-finger flap may appear to be a procedure fraught with technical demands and potential
pitfalls, our extensive experience with it suggests otherwise. The thickness of tissue transferred from the
dorsum of the adjacent digit to the amputated tip is adequate with good color match. The appearance of the
dorsal defect and skin graft is often quite good as well. However, skin color mismatch with transfer of dorsal
skin to the volar aspect in patients with darker skin tones should be considered. Similarly, dorsal skin with
excessive hair should not be transferred to volar wounds or defects. Recovery after flap division is about 3
weeks for lighter work and 6 weeks or more for manual labor. Nicolai and Hentenaar report that 75% of
patients at 4 years of follow-up have twopoint discrimination within 2 mm of their opposite side. However,
only those younger than 21 years of age had consistent return of sensation. Kleinert et al. reported results
by age. In patients younger than 12 years, more than 90% had 6 mm or less two-point discrimination; by 40
years, this declines to only 40%.
For all of these reasons, the cross-finger flap, as with all of these reconstructive alternatives, fall within the
purview of the surgeon interested and experienced in the care of the hand.
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FIGURE 29-25 Summary of treatment options based on the level of amputation and the angle of tissue loss.
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FUTURE DIRECTIONS/HORIZONS
Other new techniques to promote healing of injured fingertips are undergoing evaluation. Taras et al. used
acellular dermal template (Integra Dermal Regeneration Template, Integra LifeSciences) to reconstruct digital
injuries with exposed bone, joint, tendon, and hardware. Wounds from 1 to 1.4 cm2 were treated with the
acellular dermal template followed by full-thickness skin grafting an average 24 days later. The level IV study
reported generally good results, demonstrating that the acellular dermal template can be an alternative and
effective skin substitute in complex digital injuries (29).
There is insufficient evidence to determine the best treatment method for composite defects of the fingertips. To
date, there have been no prospective randomized clinical trials to evaluate one method versus another. The
multitude of case series with level 4 evidence evaluating the various methods of composite tissue reconstruction
are too disparate to allow for objective analysis and conclusions (30).
REFERENCES
1. Hattori Y, Doi K, Ikeda K, et al.: A retrospective study of functional outcomes after successful replantation
versus amputation closure for single fingertip amputations. J Hand Surg Am 31(5): 811-818, 2006.
2. Hattori Y, Doi K, Sakamoto S, et al.: Fingertip replantation. J Hand Surg Am 32(4): 548-555, 2007.
3. Wang K, Sears ED, Shauver MJ, et al.: A systematic review of outcomes of revision amputation treatment
for fingertip amputations. Hand 8(2): 139-145, 2013.
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prospective study. Am J Emerg Med 9(3): 209-210, 1991.
5. Gellman H: Fingertip-nail bed injuries in children: current concepts and controversies of treatment. J
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6. Costello J, Howes M: Best evidence topic report. Prophylactic antibiotics for subungual haematoma.
Emerg Med J 21(4): 503, 2004.
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versus suture repair for nail bed injuries. J Hand Surg Am 33(2): 250-253, 2008.
8. Mignemi ME, Unruh KP, Lee DH: Controversies in the treatment of nail bed injuries. J Hand Surg Am
38(7): 1427-1430, 2013.
9. DaCruz DJ, Slade RJ, Malone W: Fractures of the distal phalanges. J Hand Surg Br 13(3): 350-352, 1988.
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in children and adults. J Hand Surg Br 26(3): 201-206, 2001.
11. Venkataswami R, Subramanian N: Oblique triangular flap: a new method of repair for oblique
amputations of the fingertip and thumb. Plast Reconstr Surg 66(2): 296-300, 1980.
12. Lim GJ, Yam AK, Lee JY, et al.: The spiral flap for fingertip resurfacing: short-term and long-term results.
J Hand Surg Am 33(3): 340-347, 2008.
13. Katz RD: The anterograde homodigital neurovascular island flap. J Hand Surg Am 38(6): 1226-1233,
2013.
14. Foucher G, Smith D, Pempinello C, et al.: Homodigital neurovascular island flaps for digital pulp loss. J
Hand Surg Br 14(2): 204-208, 1989.
15. Henry M, Stutz C: Homodigital antegrade-flow neurovascular pedicle flaps for sensate reconstruction of
fingertip amputation injuries. J Hand Surg Am 31A(7): 1220-1225, 2006.
16. Chen CT, Wei FC: Lateral-dorsal neurovascular island flaps for pulp reconstruction. Ann Plast Surg
45(6): 616-622, 2000.
17. Ni F, Appleton SE, Chen B, et al.: Aesthetic and functional reconstruction of fingertip and pulp defects
with pivot flaps. J Hand Surg Am 37(9): 1806-1811, 2012.
18. Momeni A, Zajonc H, Kalash Z, et al.: Reconstruction of distal phalangeal injuries with the reverse
homodigital island flap. Injury 39(12): 1460-1463, 2008.
19. Tonkin MA, Ahmad TS: The reconstruction of a dorsal digital defect using a reverse homodigital island
flap incorporating vascularized tendon. J Hand Surg Br 22(6): 750-751, 1997.
20. Han SK, Lee BI, Kim WK: The reverse digital artery island flap: clinical experience in 120 fingers. Plast
Reconstr Surg 101(4): 1006-1011, 1998.
21. Kojima T, Tsuchida Y, Hirase Y, et al.: Reverse vascular pedicle digital island flap. Br J Plast Surg 43(3):
290-295, 1990.
22. Bene MD, Petrolati M, Raimondi P, et al.: Reverse dorsal digital island flap. Plast Reconstr Surg 93(3):
552-557, 1994.
23. Yildirim S, Avci G, Akan M, et al.: Complications of the reverse homodigital island flap in fingertip
reconstruction. Ann Plast Surg 48(6): 586-592, 2002.
24. Braga-Silva J, Gehlen D, Bervian F, et al.: Randomized prospective study comparing reverse and direct
flow island flaps in digital pulp reconstruction of the fingers. Plast Reconstr Surg 124(6): 2012-2018, 2009.
25. Sano K, Ozeki S, Kimura K, et al.: Relationship between sensory recovery and advancement distance of
oblique triangular flap for fingertip reconstruction. J Hand Surg Am 33(7): 1088-1092, 2008.
26. Fitzcharles-Bowe C, Denkler K, Lalonde D: Finger injection with high-dose (1:1,000) epinephrine: Does it
cause finger necrosis and should it be treated? Hand 2(1): 5-11, 2007.
27. Mann T, Hammert WC: Epinephrine and hand surgery. J Hand Surg Am 37(6): 1254-1256, 2012.
28. van den Berg WB, Vergeer RA, van der Sluis CK, et al.: Comparison of three types of treatment
modalities on the outcome of fingertip injuries. J Trauma Acute Care Surg 72(6): 1681-1687, 2012.
29. Taras JS, Sapienza A, Roach JB, et al.: Acellular dermal regeneration template for soft tissue
reconstruction of the digits. J Hand Surg Am 35(3): 415-421, 2010.
30. Bickel KD, Dosanjh A: Fingertip reconstruction. J Hand Surg Am 33A(8): 1417-1419, 2008.
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RECOMMENDED READING
Atasoy E, Ioakimidis E, Kasdan ML, et al.: Reconstruction of the amputated fingertip with a triangular volar
flap: a new surgical procedure. J Bone Joint Surg 52(5): 921-936, 1970.
Bojsen-Moller J, Pers M, Schmidt A: Fingertip injuries: late results. Acta Chir Scand 122: 177-183, 1961.
Curtis RM: Cross finger pedicle flap and hand surgery. Ann Surg 145: 650-655, 1957.
Douglas BS: Conservative management of guillotine amputation of the finger in children. Aust Paediatr J 8:
86, 1972.
Flatt AE: The thenar flap. J Bone Joint Surg 98: 80-85, 1957.
Holm E, Zachariae L: Fingertip lesions: an evaluation of conservative treatment versus free skin grafting.
Acta Orthop Scand 5: 382, 1974.
Kleinert HE, McAlister CG, MacDonald CJ: A critical evaluation of cross finger flaps. J Trauma 4: 756-763,
1974.
Kutler W: A method for repair of finger amputation. Ohio State Med J 40: 126, 1944.
Louis OS, Jebson PJL, Graham TJ: Amputations. In: Green DP, Hotchkiss RN, Pederson WC, eds. Green's
operative hand surgery. 4th ed. Vol. 1. Philadelphia, PA: Churchill Livingstone, 1999.
Nicolai JPA, Hentenaar G: Sensation in cross-finger flaps. Hand 3: 12-16, 1981.
Nyström A, Backman C, Backman C, et al.: Digital amputation, replantation, and cold intolerance. J Reconstr
Microsurg 7: 175-178, 1991.
Smith RJ, Albin R: Thenar “H-Flap” for fingertip injuries. J Trauma 6: 778-781, 1976.
Taras JS, Saplenza A, Roach JB, et al.: Acellular dermal regeneration template for soft tissue reconstruction
of the digits. J Hand Surg 35A: 415-421, 2010.
Wang K, Sears ED, Shauver MJ, et al.: A systematic review of outcomes of revision amputation treatment for
fingertip amputations. Hand 8(2): 139-145, 2013.
Chapter 30
Decision Making and Performance of Digital Ray Amputation
Varun K. Gajendran
Harry A. Hoyen
Ray amputation refers to the ablation of digital elements at or just distal to the carpometacarpal joint of a
particular ray. It is most commonly indicated following traumatic injuries, such as partial amputations, failed
replantations, or ring avulsion injuries, and also in cases of infection, ischemic gangrene, or as part of a tumor
resection. In the pediatric setting, it can also be utilized to close the gap in a congenital cleft hand or to open up
the first web space, with the goal of improving functional use of the hand in both cases. A relative
contraindication to ray amputation is the availability of alternate procedures that preserve digital length without
compromising hand function.
When performed for the appropriate indications, ray amputation can result in a significant improvement in both
cosmesis and hand function. It is generally performed as an elective procedure, even in the traumatic setting. If
the metacarpal is potentially salvageable, it should be retained at the initial operation in the event that it is
needed in the future as a source of spare parts for the reconstruction of other digits. If the metacarpal is not
salvageable or it is needed to acutely reconstruct more critical digits such as the thumb, an acute ray amputation
may be performed.
There are certain situations where a ray amputation is particularly effective and gratifying for the patient. In
cases where the index finger has inadequate length, mobility, or sensation to the point that it is bypassed by the
patient or leads to stiffness of the other digits, resection of the index ray can lead to a much more functional
hand. A short index finger stump due to amputation at the proximal phalanx or metacarpophalangeal (MCP) joint
level may be converted electively to a ray amputation if the stump interferes with pinch and hand function.
Similarly, when there is a short stump of the middle or ring finger left after a partial amputation, it leaves a large
cleft in the middle of the hand that allows small objects to slip through and also makes grasping objects difficult.
In these cases, a ray amputation of the partially amputated ray, combined with closure of the cleft or
transposition, can produce a cosmetically and functionally improved hand.
The preoperative evaluation of a patient scheduled to undergo ray resection includes the standard clinical
history and physical examination supplemented with the appropriate imaging studies. For the majority of patients,
plain radiographs are sufficient. If a ray resection is being performed as part of the excision of a malignant tumor,
magnetic resonance imaging (MRI) and/or computed tomography (CT) may help guide incision placement and
surgical dissection to ensure negative residual tumor margins. The patient should be counseled preoperatively
with respect to the anticipated appearance
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and function of the hand. Providing patients with real postoperative photographs before the surgery is
particularly helpful. Although most ray resections are performed electively, the specific timing of the procedure is
largely dependent on the condition being treated. In the case of a malignant tumor, the procedure should be
carried out as early as possible to maximize the chances of obtaining negative margins with a ray amputation.
When performed for ischemia and questionable viability of the digit, it may be more appropriate to wait until the
necrosis has more clearly “declared itself.”
SURGICAL TECHNIQUE
The procedure can be performed under either general anesthesia or regional anesthesia with sedation,
depending on the preferences of the patient, surgeon, and anesthesiologist. The patient is positioned supine on
the operating table with the arm extended over a hand board. A well-padded nonsterile tourniquet is used. When
the operation is being performed for infection or tumor, exsanguination is performed with elevation for several
minutes rather than the use of an Esmarch to obviate the theoretical risk of dissemination of the tumor or
infection. Loupe magnification should be used to avoid injury to small cutaneous nerves that can lead to
neuromas and also to achieve meticulous hemostasis and reduce postoperative swelling.
Although there are subtle differences in the techniques employed for resections of the individual rays, there are
many steps that they share in common:
1. Midline dorsal skin incision over the metacarpal with racket-shaped extensions distally over the proximal
phalanx
2. Division of the extensor tendon at the metacarpal base and reflection of it distally
3. Subperiosteal stripping of the metacarpal
4. Carpometacarpal disarticulation or metacarpal base osteotomy
5. Distal release of the intrinsic tendons on both sides
6. Division of the deep intermetacarpal ligaments
7. Dissection of the neurovascular structures on either side of the metacarpal
8. Division of the flexor tendons, allowing for proximal retraction
9. Release of all remaining palmar fascia
10. Ray removal
11. Proximal division of the neurovascular structures and burial of the nerve in the interosseous space
12. Transposition or approximation of adjacent remaining rays
13. Skin flap contouring and closure
14. Application of dressings and splint
A racket-shaped incision is marked out around the ray to be amputated, which in this example is the ring ray (Fig.
30-1). The incision lies over the dorsal midline of the metacarpal shaft and extends on
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either side around the proximal phalanx to the midproximal phalangeal level. Care is taken to ensure that
adequate distal skin is saved for later web closure. This incision may need to be carefully modified in the patient
with a malignant tumor to permit complete tumor excision and negative residual tumor margins. The dorsal veins
are carefully ligated to obtain hemostasis throughout the approach. The extensor tendons to the amputated ray
are divided proximally at the level of the metacarpal base and reflected distally (Fig. 30-2). The juncturae
tendinae, if present, are divided such that the extensor tendon can be reflected out to the distal wound margin
over the proximal phalanx (Fig. 30-3). The periosteum is incised and stripped around the base of the metacarpal.
The metacarpal is then reflected distally.
FIGURE 30-1 A racket-shaped incision is made as far distally as possible on the proximal phalanx, thereby
preserving the adjacent commissures to allow reconstruction of the web during closure.
In the case of a ring ray amputation, there are no tendinous attachments to the ring metacarpal, and therefore,
the entire metacarpal may be removed. In the case of the index, long, and small metacarpals, the base of the
metacarpal and the insertion sites of the extensor carpi radialis brevis (ECRB), extensor carpi radialis longus
(ECRL), and extensor carpi ulnaris (ECU), respectively, can be preserved by osteotomizing the base of the
metacarpal just distal to the insertions. A power saw is used to complete the osteotomy. Alternatively, the
tendinous insertion may be released and the tendon transferred and reattached to the carpus more proximally,
although we do not prefer to use this approach.
FIGURE 30-2 The extensor apparatus is reflected distally, and the soft tissues around the proximal metacarpal
are subperiosteally elevated.
FIGURE 30-3 The tendinous interconnections between the small, ring, and long fingers are divided, and the
proximal aspect of the extensor digitorum communis tendon to the ring finger is divided and reflected distally.
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Once the metacarpal is reflected, the dorsal and volar interosseous tendons and radial-sided lumbrical tendons
are tenotomized. The deep intermetacarpal ligaments are then exposed and released from the volar plate. The
volar portion of the hand incision is then completed (Fig. 30-4). The neurovascular structures are carefully
identified and dissected out distally. The digital nerves are divided and tagged for later positioning. The digital
arteries are cauterized distal to the takeoff of the branches supplying the palmar skin. The flexor tendons are
retracted distally and sharply divided as far proximally as possible, permitting them to retract proximally. The
remaining attachments of the palmar fascia are released from the metacarpal shaft. The amputated ray is then
removed from the field and passed off as specimen.
The tourniquet is then released and hemostasis is obtained. The residual digital nerve ends are then transposed
into the interosseous space vacated by the metacarpal, and the periosteal sleeve is closed around them in an
effort to prevent symptomatic neuroma formation. If approximation of the remaining metacarpal shafts is
necessary, the deep intermetacarpal ligaments are approximated and sutured together with nonabsorbable
suture to draw the metacarpals together (Figs. 30-5 and 30-6).
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Transmetacarpal pinning to secure the desired position may be done at the discretion of the surgeon by utilizing
two 0.045-inch or 0.062-inch Kirschner wires inserted parallel to one another.
FIGURE 30-4 The racket-shaped incision is extended volarly as demonstrated above.
FIGURE 30-5 The deep intermetacarpal ligaments are closely approximated, and the skin of the commissure is
carefully fashioned to create a new web.
FIGURE 30-6 Following removal of the ray, the deep intermetacarpal ligaments are closely approximated.
FIGURE 30-7 A: Ray transposition may be accomplished by leaving the metacarpal base intact with its
tendinous insertion and transferring an osteotomized adjacent ray. In this patient, the base of the ring metacarpal
was preserved following ray resection. The small finger metacarpal was then osteotomized and transferred to the
ring metacarpal. Fixation was achieved with a plate and screws, but the metacarpal has clearly been overly
shortened. B: Lateral view of the same patient shows the apex dorsal and shortened malunion of the metacarpal
osteotomy, which resulted in a prominent metacarpal head within the palm, pain with gripping, and
hyperextension at the MCP joint.
If ray transposition is chosen, the technique depends on the particular ray that has been amputated. In the case
of a ring ray amputation, the small metacarpal may be transposed to the base of the amputated ring metacarpal,
and there are two distinct methods that may be utilized. The first is to release the fifth carpometacarpal joint and
preserve the ECU insertion while transposing the entire small metacarpal base to the radial articular facet of the
hamate from its anatomic ulnar articular facet. Although the new articulation is stabilized by pinning, it is not ideal
because of the variable and nonreciprocating anatomy of the new articulation. An alternative option involves
making an osteotomy of the small metacarpal just distal to the ECU insertion and transposing it onto the ring
metacarpal base (Fig. 30-7). This technique requires skeletal fixation with plates and screws,
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interosseous wires, or crossed Kirschner wires. With either method of transposition, it is essential that digital
rotation and angulation be carefully evaluated to avoid a functionally disabling malunion (Fig. 30-8).
The wound is then copiously irrigated with sterile saline prior to closure. A drain may be placed at the discretion
of the surgeon and removed after 24 hours. The deep dermal layer is closed with absorbable monofilament
suture, and the skin is closed with nonabsorbable, monofilament suture (Figs. 30-9 and 30-10). The commissure
is fashioned to recreate a natural looking web space that is not too loose or too tight. A nonadherent dressing,
such as Xeroform, is placed over the incisions,
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followed by a bulky gauze dressing that is incorporated into a well-padded volar resting splint that extends from
the midforearm proximally and includes the MCP joints distally. The MCP joints are immobilized at 45 degrees of
flexion and the proximal interphalangeal joints are left free. When rigid plate fixation is used, splinting or casting
may not be required depending on the surgeon's judgment.
FIGURE 30-8 Full closure of the hand was possible despite malrotation between the long and small fingers.
FIGURE 30-9 The skin is closed on both the dorsal and volar surfaces after appropriate contouring.
FIGURE 30-10 Nearly 6 months following a ring ray amputation, the web between the small and long fingers has
been reconstructed by careful approximation of the deep intermetacarpal ligaments and skin closure.
FIGURE 30-11 The dorsal and palmar racket-shaped incisions are similar to those used for the ring-finger
amputation.
Figures 30-11, 30-12, 30-13, 30-14, 30-15, 30-16, 30-17 and 30-18 show the case of a long ray amputation for
digital ischemia with an excellent cosmetic and functional outcome.
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FIGURE 30-12 This patient has digital ischemia of the nondominant left long finger due to a vascular
malformation. Again, a racketshaped incision is used for the long ray amputation, but in this case, the volar
portion of the incision was made more extensile to deal with the vascular malformation.
FIGURE 30-13 The neurovascular structures have been carefully dissected out and retracted, and the flexor
tendons have been exposed.
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FIGURE 30-14 The ray has been completely detached from its base in this case. The extensor carpi radialis
brevis (ECRB) tendon was transferred to a new insertion on the carpus.
FIGURE 30-15 The commissures were carefully approximated during closure, preserving a normal-appearing
web space.
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FIGURE 30-16 Six months following the procedure, the dorsal commissure is well preserved, providing a
satisfactory cosmetic appearance.
FIGURE 30-17 Radiographs of the hand from Figure 30-16 shows complete ablation of the long metacarpal with
distal reapproximation of the deep intermetacarpal ligaments.
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FIGURE 30-18 A full, normal grasp was achieved after the procedure.
Special Considerations
Following index ray amputations, no further reconstruction is generally necessary because the first web
space is open and readily allows opposition between the thumb and the middle ray. A transfer of the first
dorsal interosseous to the second dorsal interosseous muscle does not improve strength or function and is
therefore not indicated.
For central ray amputations involving the long and ring rays, the central defect is problematic because it
allows small objects to pass through and also interferes with normal pinch and power grip. After long ray
amputations, the index metacarpal can be osteotomized at its base and transposed ulnarly to the base of
the long metacarpal, or the intermetacarpal ligaments between the index and ring rays can be tightened to
close the web space as described above. Similarly, after ring ray amputations, the small metacarpal can be
osteotomized at its base and transposed radially to the base of the ring metacarpal, or the small metacarpal
can be transposed from the ulnar articular facet of the hamate to the radial articular facet of the hamate, or
the intermetacarpal ligaments between the long and small metacarpals can simply be tightened to close the
web space and avoid performing a transposition.
The small ray is unique in that it plays an important role in hooking objects and power grip, both of which
are especially important to laborers. Since a ray amputation narrows the hand and causes a small but
important loss of power grip, consideration should be given in laborers to performing an amputation at the
MCP joint level. This preserves the breadth of the palm, thereby theoretically preserving more power grip.
Conversely, a small ray amputation is a good option for patients in whom cosmesis and dexterity are more
important than power grip. The base of the small metacarpal with its ECU insertion should be preserved,
along with all of the hypothenar musculature, which provides padding to the ulnar aspect of the hand and
maintains the width to the palm.
Postoperatively, the hand should be continuously elevated for a minimum of 48 to 72 hours, and as much as
possible during the first week, for edema control. Active and passive digital motion should be initiated
immediately, and adequate analgesia along with supervision of a hand therapist is often helpful. Sutures should
be removed at 2 weeks, and a home program consisting of digital motion, scar massage, and desensitization is
initiated at this time. A compressive stocking or glove, along with an aggressive edema control program, may be
used when there is excessive swelling. After the initial splint is removed at 2 weeks, a supportive orthosis as
described below can also be used until sufficient soft-tissue and osseous healing has occurred.
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When closure of the central defect is accomplished by approximation of the intermetacarpal ligaments, a splint
should be used for 4 weeks to allow for soft-tissue healing. When the ray has been transposed, a splint should
be maintained for at least 2 months and sometimes longer until there is clinical and radiographic evidence of
bony union. If transmetacarpal pins are used, they should be removed in the office at 6 weeks. After splinting has
been discontinued and soft-tissue and osseous healing are adequate, a strengthening program is initiated. The
therapist may focus on work-related tasks at this time to ease the transition back to work. Generally, patients
return to their full activity level without restrictions at about 3 months.
RESULTS
Ray amputation, when performed for the correct indications and in a technically proficient manner, is an
extremely rewarding procedure for most patients. Most of the current literature deals with index ray
amputations, and the data demonstrate a 20% loss of grip strength, key pinch, and supination strength,
along with a 50% loss of pronation strength when compared to a normal hand. Despite these limitations,
patients are typically very satisfied with the improvement in function, and they are also pleasantly surprised
at the cosmetic appearance and social acceptance of the new hand (Fig. 30-18). The majority of patients
return to their preinjury occupations.
Some patients may experience posttraumatic stress, depression, and/or sleep disorders either
preoperatively or during the early postoperative period. Patients at risk for these setbacks need to be
carefully identified and counseled preoperatively, and some may require the assistance of a psychologist or
psychiatrist. We have found that the majority of patients who are unsatisfied or do poorly following ray
amputation are involved in nonsettled litigation or workers' compensation claims. However, we still offer the
procedure to these patients when it is indicated and expected to improve their function. We prefer to leave
the insertions of the ECRB, ECRL, and ECU intact on the osteotomized index, long, and small metacarpal
bases, respectively, and we avoid transposition with skeletal fixation if possible because of the technical
challenges, risk of nonunion and malunion, and the need for an extended period of postoperative
immobilization. The literature has not demonstrated any differences between transposition and tightening of
the intermetacarpal space in terms of functionality of the hand.
COMPLICATIONS
In addition to problems with wound healing and infection, there are a few additional complications that can
occur following ray amputations.
Nonunion
If digital ray transposition is performed in conjunction with a metacarpal osteotomy, a nonunion can occur,
particularly when the osteotomy is made more distally in the diaphysis rather than in the well-vascularized
metaphysis. The risk of nonunion is higher in diabetics and smokers due to their compromised circulation.
Since ray amputation is usually an elective procedure, smokers should be advised to quit smoking for 6
weeks prior to surgery and for 3 months after surgery. More rigid fixation techniques such as plates and
screws may theoretically have a lower risk of nonunion than the use of K-wires. If a nonunion does occur
and infection has been ruled out, the nonunion site must be thoroughly debrided and the fixation revised to
plates and screws with the addition of autologous bone grafting.
Malunion
Malunion following ray transposition leads to a rotational and/or angular deformity, and this can be avoided
by careful intraoperative assessment of the position of the ray. The functional consequence of a rotational
malunion is digital scissoring or divergence that can compromise pinching or gripping (Fig. 30-8). Following
temporary skeletal fixation, passive motion of the fingers should be assessed and normal rotation confirmed
prior to definitive skeletal fixation. An angular malunion can adversely affect MCP joint motion. The more
common apex dorsal deformity can result in an MCP joint extensor lag and prominence of the metacarpal
head in the palm, which can interfere with normal power grip. If a malunion compromises hand function, it
should be revised to correct the offending deformity. Rotational osteotomies can be performed at the
metacarpal base, and correction of angular deformities should be done through closing wedge osteotomies
if possible to maximize the chances of healing. Fixation can be achieved with K-wires or plates and screws,
and bone grafting is usually not necessary but may be done for opening wedge osteotomies.
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Postoperative Stiffness
Postoperative stiffness is uncommon and can be avoided with aggressive edema control, adequate
analgesia, and early digital motion. The involvement of a hand therapist early on in the postoperative
process is critical. Static and dynamic splints may be used if motion is still lagging behind after 4 to 6 weeks.
Surgical releases are rarely necessary but may be considered after a minimum of 3 months when motion
has plateaued with therapy and the soft tissues have healed and stabilized.
Neuroma Formation
Symptomatic neuromas may occur despite taking great care during dissection of the nerve and transferring
it into the interosseous space or because the dorsal cutaneous branches of the ulnar or radial nerves have
become entrapped in the dorsal scar tissue. When a diagnosis of neuroma is suspected clinically,
exploration of the involved nerve with careful dissection and burial into the interosseous space or a bed of
deep, well-protected tissue is indicated.
Skin and Wound Problems
Wound problems may occur if too much skin is inadvertently excised, if the web space is closed too tightly,
or if too much skin is left behind in the web space. Thus, the skin incisions and fashioning of the web should
be performed carefully and meticulously. If too much skin was removed, resulting in a tight web space or
creep, a secondary procedure for excision of the cutaneous tether and skin grafting will be necessary. If too
little skin was removed, a secondary procedure to close the web space is indicated. Other wound healing
problems are relatively rare owing to the rich vascularity and excellent healing potential in this area.
Flexor and extensor tendon Adhesions
When the soft tissues are severely injured either traumatically or during surgical dissection and/or early
digital motion is not instituted, flexor and/or extensor tendon adhesions can occur. These adhesions can
detrimentally affect the motion of the adjacent fingers. This is due to the fact that the flexor digitorum
profundus (FDP) tendons share a common muscle belly, and the common extensor tendons are
interconnected through the juncturae tendinae. When there is a limitation of active versus passive motion,
surgical tenolysis can be performed after a minimum of 3 months if the wound is fully healed and stable.
ACKNOWLEDGMENTS
We would like to acknowledge Dr. Peter Jebson and Dr. Dean Louis for their work on the previous edition of this
chapter.
RECOMMENDED READING
Carroll RE: Transposition of the index finger to replace the middle finger. Clin Orthop 15: 31-34, 1959.
Carroll RE: The level of amputation in the third finger. Am J Surg 97: 477-483, 1959.
Colen L, Bunkis J, Gordon L, et al.: Functional assessment of ray transfer for central digital loss. J Hand
Surg Am 10: 232-237, 1985.
Hanel DP, Lederman ES: Index transposition after resection of the long finger ray. J Hand Surg Am 18: 311-
317, 1993.
Hyroop GL: Transfer of a metacarpal, with or without its digit, for improving the function of the crippled hand.
Iselin F, Peze W: Ray centralization without bone fixation for amputation of the middle finger. J Hand Surg Br
13: 97-99, 1988.
Louis DS, Jebson PJL, Graham TJ: Amputations. In: Green DP, ed. Operative hand surgery. 6th ed. New
York: Churchill-Livingstone, 1998.
Peacock EE: Metacarpal transfer following amputation of a central digit. Plast Reconstr Surg 29: 345-355,
1962.
Peimer CA, Wheeler DR, Barrett A, et al.: Hand function following single ray amputation. J Hand Surg Am 24:
1245-1248, 1999.
Plasschaert MJJT, Hage JJ: A web-saving incision for the amputation of the third or fourth ray of the hand. J
Hand Surg Br 13: 340-341, 1988.
Posner MA: Ray transposition for central digital loss. J Hand Surg Am 4: 242-257, 1979.
Steichen JB, Idler RS: Results of central ray resection without bony transposition. J Hand Surg Am 11: 466-
474, 1986.
Chapter 31
Digital Sympathectomy
Imran K. Choudhry
Beth Paterson Smith
L. Andrew Koman
INTRODUCTION
Digital sympathectomy is a surgical procedure that mechanically disrupts sympathetic connections between the
parallel nerves and sympathetic fibers in the adventitia accompanying distal vessels (Fig. 31-1). These
sympathetic neural structures can potentiate inappropriately prolonged vasospasm or stimulate inappropriate
arteriovenous shunting. Following digital sympathectomy, arterial vasoconstriction decreases and nutritional
perfusion improves, which, in turn, decreases symptoms and may facilitate healing of refractory ulcers or sores
(1,2). Synonyms of digital sympathectomy include periarterial sympathectomy, peripheral sympathectomy,
digital artery sympathectomy, and arteriolysis.
Peripheral vascular disorders of the upper extremity are challenging to diagnose, treat, and manage. Vascular
insufficiency and vasospastic disease may produce pain, cold intolerance, numbness, digital ulceration, and/or
infection. Vascular pathology negatively impacts health-related quality of life, function, and productivity. The
pathoanatomy of peripheral vascular disorders can be secondary to congenital and/or acquired conditions that
affect vascular structure or function (e.g., an occlusive event [thrombosis/embolism] or vasomotor control
abnormalities [precipitated by trauma or disease]). Vasoconstriction is stimulated by sympathetic branches
accompanying sensory nerves innervating distal arteries and by sympathetic nerves on arterial adventitia.
Sympathetic excitation within vascular smooth muscle stimulates the release of á-adrenergic neurotransmitters,
which bind with postsynaptic sympathetic receptors producing smooth muscle contraction (3,4,5). Increased
sympathetic tone can occur after soft-tissue or bony trauma, nerve injury, or vessel injury or from disease states.
Thrombosis or embolism often produces a reactive vasospasm, which, if it occurs concomitantly, produces
inadequate collateral circulation, leading to digital signs and symptoms (2,6). Alleviating sympathetic tone via
surgical digital arterial sympathectomy (DAS) can limit vasoconstriction and reduce hand ischemia by increasing
nutritional flow (7,8,9,10,11).
The Wake Forest Classification of Vascular Disease (Table 31-1) is used to guide treatment options in patients
with peripheral vascular disorders. Raynaud's disease (Group I) is idiopathic and selflimited and patients rarely
require surgical intervention. Although symptoms are common after nonvascular injury, patients with secondary
vasospasm (Group II) almost never require sympathectomy. However, sympathectomy may be beneficial for
managing refractory symptoms in patients with Raynaud's phenomenon with inadequate collaterals (Group IIB)
and secondary vasospasm from occlusive disease with inadequate collaterals (Group IIIB). Patients with
Raynaud's phenomenon who have adequate collaterals (Group IIA) and patients with secondary vasospasm
from occlusive disease who have adequate collaterals (Group IIIA) rarely require digital sympathectomy (2).
The primary treatment of symptomatic vasospastic disease is medical, that is, treatment includes medications to
treat the underlying disease and calcium channel blockers and environmental adaptations (e.g., appropriate
clothing and gloves) to manage symptoms (2,5).
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FIGURE 31-1 Schematic of sympathetic innervation of digital artery. There are direct connections between the
digital artery and the parallel digital nerve as well as sympathetic fibers on the surface of the vessel adventitia.
TABLE 31-1 The Wake Forest Classification of Vascular Disease
Group Disorder Etiology
1. Raynaud's disease idiopathic

2. Raynaud's phenomenon collagen vascular disease
1. Adequate collateral circulation
2. Inadequate collateral circulation
3. Occlusive vasospasm occlusive disease
1. Adequate collateral circulation thrombosis/embolism
2. Inadequate collateral circulation
4. Secondary vasospasm nonvascular injury
Nerve/bone/soft tissue
INDICATIONS FOR DIGITAL ARTERIAL SYMPATHECTOMY

Symptoms and physical manifestations of vasospastic disease can be caused by or complicated by (a) occlusive
events (thrombosis and embolism) or vasospastic disorders, (b) abnormal vasomotor control after trauma with or
without occlusive events, (c) collagen vascular disorders, or (d) a combination of the above. Raynaud's
phenomenon and inappropriate vasospasm can produce pain, intolerance to cold, and functional impairment.
When the phenomenon is associated with occlusive events, ulcers may result and progression to gangrene may
occur. Patients who experience vasospasm after posttraumatic, acute thrombosis or embolism can benefit from
digital sympathectomy when arterial damage is not reconstructible, collaterals are inadequate, or multilevel
arterial damage is present (2,6,11,12,13,14,15,16,17,18,19,20,21,22).
Specific Indication for Digital Arterial Sympathectomy

To manage refractory vasospasm and inappropriate arteriovenous shunting in patients with vasospastic or
vasoocclusive disorders under the following conditions:
Refractory symptoms that continue in spite of appropriate medical management

As an adjunctive treatment to compliment arterial reconstruction or resection and ligation in patients with
occlusive disease
In patients with collagen vascular disease and refractory vasospastic symptoms with physical findings
secondary to Raynaud's phenomenon
For treatment of nonhealing digital ulcers or sores
As an adjunct to digital amputation in patients with vasospastic disorders in order to facilitate healing
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Contraindications
Nonsalvageable distal structures should be amputated.
Patients with atherosclerotic peripheral vascular disease with vessel calcification and irreversible vasospasm.
Calcific arteritis with minimal or no response to vasodilators
Atherosclerotic disease associated with dialysis

Atherosclerotic Buerger's disease without significant vasospastic disorder
Gross infection.
Concern over patient safety because of medical comorbidities.
PREOPERATIVE PREPARATION AND EVALUATION

Comprehensive history (2)
Document details of any trauma
Documentation of familial or personal coagulation issues
Drug use, especially intra-arterial/intravenous
Exposure to and/or use of smoke or smokeless tobacco products
Familial or personal history of collagen vascular disease
Symptoms and signs including pain, cold tolerance, swelling, digital color changes, sores or ulcers, and
delayed wound healing
Triphasic digital color changes; the frequency and duration of color changes must be documented.
Physical Examination (2)

Evaluation of the neck and entire upper extremity
Assessment of capillary refill, turgor, and integrity of skin and nails
Evaluation of peripheral pulses
Allen test
Evaluation to determine the presence of thoracic outlet syndrome
Additional Testing
Doppler mapping
Ultrasound
Noninvasive vascular studies
Digital brachial indices and radial/ulnar brachial index
Evaluation of vasomotor tone and components of perfusion (23,24,25)
Stress testing
Radiographic imaging (2)
Arteriography—using digital subtraction
MR angiography
CT angiography
TECHNIQUES
A. Digital Sympathectomy of Isolated Digits (7,11)
Sympathectomy of an individual digit: CPT 64820
Microsurgical techniques requiring use of microscope: CPT 69990 (often bundled)
Anesthesia
Regional anesthesia is recommended in order to minimize postoperative pain and vasospasm; long-acting
scalene, axillary, or brachial blocks can be used.
General anesthesia is appropriate in selected patients; the use of mechanical deep vein thrombosis (DVT)
prophylaxis is recommended based upon patient age and coagulation profile.
Mechanical DVT compression devices should be applied to the lower extremities.
Consideration should be given to placement of a Foley catheter if concomitant arterial reconstruction is a
possibility and operative time is a consideration.
Procedure (Fig. 31-2)

Mark the operative site.
Perform a presurgical time out.
Administer prophylactic antibiotics.
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Position the patient supine on a standard operating room table with the operated hand placed on a traditional
hand table.
Position the microscope so that it is easily accessible to the surgeon.
Apply a tourniquet to the upper arm using appropriate padding to protect soft tissue; preset the tourniquet
pressure to 100 mg of mercury above the systolic blood pressure.
Prepare the extremity below the elbow with “clear prep solution” to allow for the assessment of capillary refill
when the tourniquet is released.
Assess perfusion and refill prior to exsanguination.
Exsanguinate the extremity with an Esmarch or elastic bandage and elevate the tourniquet.
FIGURE 31-2 Incision for DAS of single digit. A Brunner incision is utilized, and the radial and ulnar
neurovascular bundles are isolated prior to transection of the connection from the digital nerve to the digital
artery and partial removal of nerves in the superficial adventitia. A microscope is used for the dissection.
Incision
Use a marker to outline the Brunner zigzag incision extending from the distal palmar crease to the middle of
proximal phalanx (Fig. 31-2).
Using Loupe Magnification (2.5 to 6×)

Identify the radial and ulnar proper digital arteries and nerves at the MCP crease and create a 2- to 3-cm
exposure.
Incise Grayson's ligament to facilitate surgical exposure.
Dissect the venae comitantes from the digital artery(ies) and cauterize or ligate the vessels as needed.
Place vessel loops around the arteries.
Position the operating microscope over the operative field and focus.
Using the Operating Microscope

Transect any direct connections from the digital nerve to the artery.
Dissect adventitia from the vessels using the microscope and microinstruments for a length of 0.5 to 2.0 cm.
Inspect vessels for damage and cauterize or ligate any transected arterial branches and cauterize any veins.
Repair any damaged arteries with 9-0 or 10-0 suture on 75- to 135-μm needles.
Anticoagulation is unnecessary unless vascular repair is required.
Deflate Tourniquet
Check capillary refill and turgor.
Leave vessel loops in place.
Irrigate wound.
Obtain hemostasis using a bipolar cautery.
If necessary, ligate vessel branches with 6-0 to 8-0 suture.
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Remove vessel loops after hemostasis is achieved.
Place a small drain if there is a concern with continued bleeding.
Close wounds with nonabsorbable suture.
Apply sterile compressive dressing.
Admit the patient for 4 to 6 hours. If the patient is stable without vascular compromise or bleeding, they can be
discharged. If there are any concerns, continue hospitalization.
B. Multidigit Sympathectomy: Wake Forest Technique (1,2)

Sympathectomy individual digit: CPT 64820
Sympathectomy radial artery: CPT 64821
Sympathectomy ulnar artery: CPT 64822
Sympathectomy superficial arch: CPT 64823
Sympathectomy deep arch artery: CPT 64823
Operating microscope (often bundled): CPT 69990
Options: Four digits are often accessible through a transverse palmar incision. Using this incision, the distal
ulnar artery, superficial arch, and three common palmar arteries can be effectively exposed for surgical
procedures. The thumb and deep arch can be approached through an oblique dorsal incision over the snuffbox.
A sympathectomy of the radial and ulnar artery in the distal forearm is performed through two parallel incisions
and is synergistic (Fig. 31-3A).
FIGURE 31-3 A: An oblique incision over the distal palmar crease is utilized; it may be curved slightly over the
distal ulnar artery. B: An incision parallel and slightly ulnar to the extensor pollicis longus is used to expose the
dorsal radial artery and origin of the deep arch. C,D: Schematic of the exposure of the superficial arch, common
palmar arteries, radial artery, and ulnar artery.
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Anesthesia
Regional anesthesia is recommended in order to minimize postoperative pain and vasospasm; long-acting
scalene, axillary, or brachial blocks may be used.
General anesthesia is appropriate in selected patients; the use of mechanical DVT prophylaxis is
recommended based upon patient age and coagulation profile.
Mechanical DVT compression devices should be applied to the lower extremities.
Consideration should be given to placement of a Foley catheter if concomitant arterial reconstruction is a
possibility and operative time is a consideration.
Procedure
Mark the operative site.
Perform presurgical time out and mark operative site.
Administer prophylactic antibiotics.
Position the patient supine on a standard operating room table with the operated hand placed on a
traditional hand table.
Position the microscope so it is easily accessible to the surgeon.
Apply a tourniquet to the upper arm using appropriate padding to protect the soft tissue; preset the
tourniquet pressure to 100 mg of mercury above the systolic blood pressure.
Prepare the extremity with clear prep solution to allow for the assessment of capillary refill when the
tourniquet is released.
Assess perfusion and refill prior to exsanguination.
Exsanguinate the extremity with an Esmarch or elastic bandage and then elevate the tourniquet.
Incisions (Fig. 31-3A-D)

Four incisions are used:
1. Oblique: across the palm at the distal palmar crease

2. Longitudinal: parallel with and slightly ulnar to the radial artery
3. Longitudinal: parallel with and slightly radial to the ulnar artery
4. Slightly oblique: parallel and 1 cm ulnar to the thumb metacarpal
Using Loupe Magnification (2.5 to 6×)

1. Expose the superficial arch and palmar common digital arteries through an oblique distal palmar crease
incision.
Elevate the skin from the palmar fascia proximally and distally for 1 cm.
Obtain hemostasis with bipolar cautery.
Periodically irrigate the surgical site with normal saline.
Elevate the skin from the palmar fascia (5 to 10 mm).
Incise the palmar fascia.
Expose the superficial palmar arch, distal end of the ulnar artery, and common digital arteries and nerves
with blunt and sharp dissection.
Identify and protect connections between median and ulnar nerves.
Incise the vertical septa to permit mobilization of deep structures.
Identify and dissect the common digital arteries to index-long, long-ring, and ring-little fingers and trace
proximally to superficial arch.
Dissect the venae comitantes from common digital artery(ies) and bipolar cauterize, as needed.
Place vessel loops around common digital arteries to index-long, long-ring, and ring-little fingers and
superficial arch.
Mobilize the arterial network exposing distal ulnar artery to proper digital takeoff.
Mobilize all common digital nerves.
2. Expose the radial artery using a longitudinal incision parallel with and slightly ulnar to the radial artery.
Expose the radial artery.
Place a vessel loop around the radial artery.
Secure with Hemoclip or suture (avoid clamp).
Remove loose areolar tissue around artery.
Dissect the venae comitantes and cauterize it with the bipolar cautery.
Avoid transection of any arterial branches.
Mobilize the radial artery for 3 to 4 cm.
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3. Exposure the ulnar artery using a longitudinal incision parallel with and slightly radial to the ulnar artery.
Expose the ulnar artery just radial to the FCU tendon.
Dissect the ulnar nerve and identify the nerve of Henle. If it is present, transect the nerve.
Place vessel loop around the ulnar artery.
Secure with Hemoclip or suture (avoid clamp).
Remove loose areolar tissue around artery.
Dissect the venae comitantes and cauterize it with a bipolar cautery.
Avoid transection of any arterial branches.
Mobilize the radial artery for 3 to 4 cm.
4. Expose the deep branch of the radial artery and proximal deep arch using a dorsal oblique incision.
Identify the superficial radial nerve.

Place a vessel loop around the nerve and secure.
Mobilize the extensor pollicis longus.
Incise the deep fascia.
Mobilize the radial artery and accompanying venae comitantes.
Dissect distally and incise the fascia between the adductor and first dorsal interosseous muscles.
Identify the two to three terminal branches of the radial artery, the origin of the princeps pollicis, and the
origin of the deep arch.
Mobilize all the branches and place vessel loops around each one.
Retract the deep arch into the field.
Using the Operating Microscope

Position the operating microscope and focus.
Transect any direct nerve connections from the digital nerve to the artery.
Using microinstruments, dissect the adventitia from the:
Radial artery
Ulnar artery
Dorsal radial artery and proximal deep arch
Distal ulnar artery
Superficial arch
Common digital index-long
Common digital long-ring
Common digital ring-little
Inspect the vessels for damage and cauterize or ligate any transected arterial branches and cauterize any
veins.
Repair any damaged arteries with 9-0 or 10-0 suture on 75- to 135-μm needles.
Anticoagulation is not necessary unless vascular repair is required.
Deflate Tourniquet
Check capillary refill and turgor.
Leave the vessel loops in place.
Irrigate the wound.
Obtain hemostasis.
Remove the vessel loops after hemostasis is achieved.
Place a small drain if there is concern with continued bleeding.
Close wounds with nonabsorbable suture.
Apply sterile compressive dressing.
Admit the patient to the hospital for 4 to 6 hours. Then, if the patient is stable without vascular compromise or
bleeding, they can be discharged. If there are any concerns, continue hospitalization.
PEARLS AND PITFALLS
Complete exsanguination of the operative extremity facilitates dissection.
Ensure complete exposure by releasing vertical septa.
Skeletonize the digital vessels completely prior to engaging the microscope.
Dissect the venae comitantes from the superficial arch, distal radial artery, and common digital arteries and
cauterize any potential venous or arterial bleeders.
Fix the vessel loops with a clip or tie with suture—avoid using clamps.
Release the tourniquet prior to wound closure.
Consider using a small drain, if bleeding is a concern.
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Dress wounds with nonadherent gauze and gauze sponges.
Apply a bulky compressive dressing.
Take care not to “over tighten” the wrap.

Our preference is bias cut stockinet; however, Ace or other wraps are also appropriate.
Admit patients to the hospital for vascular checks and pain control.
Remove drain when appropriate.
Check at 4 to 6 hours, and if the patient is comfortable, he or she can be discharged.
Resume preoperative medications including calcium channel blockers and preoperative anticoagulants.
Anticoagulants are not routinely prescribed after isolated DAS procedure.
Initiate immediate finger range of motion exercises.
Remove sutures approximately 2 weeks after surgery.
COMPLICATIONS
Complications associated with periarterial sympathectomy are rare.
They include:
Flexion contractures of fingers
Delayed wound healing
Numbness
Hematoma formation
Infection
Neurovascular injury
Tissue loss
A failure to achieve desired postoperative results is possible. Vasospasm can persist and ulcers or sores
can fail to heal.
RESULTS
Digital artery sympathectomy decreases smooth muscle tone throughout the digital arterial tree and within
the microcirculation, thereby decreasing inappropriate A-V shunting leading to improved nutritional flow. In
extremities with vasospasm and without structural arterial damage, both total digital flow (reflected by digital
temperatures) and nutritional perfusion (reflected by laser Doppler fluxmetry) are increased (6). In patients
with structural arterial damage (thrombosis, embolism, traumatic transection) who do not have adequate
collateral circulation, digital sympathectomy maximizes the appropriate distribution of available flow without
increasing total flow. Therefore, coexistent occlusive disease is a critical variable effecting outcomes in
patients with collagen vascular or vasoreactive/vasospastic disease or disorders (2,6,11,20).
Vasospastic and Vasoocclusive Disorder (Collagen Vascular Disease and Occlusive
Disease with Secondary Vasospasm)
Digital artery sympathectomy decreases vascular reactivity and improves nutritional blood flow in patients
with vasospastic and vasoocclusive disorders (2,6,8,10,18,21).
Improves total flow and nutritional flow in the absence of occlusive disease
Decreases excessive and inappropriate arteriovenous shunting
Maximizes nutritional perfusion
Digital artery sympathectomy does not increase total flow in patients with collagen vascular disease and
unreconstructible distal occlusive arterial damage.
Digital artery sympathectomy facilitates healing of many refractory digital ulcers.
There is limited support in the literature for using digital artery sympathectomy in patients with Raynaud's
phenomenon as a prophylactic treatment to prevent ulcers.
The prophylactic value in preventing occlusive events in patients with vasospastic symptoms is
inconclusive.
In patients with ulcers, occlusive disease, and compromised collateral flow, prophylactic effects were
not demonstrable (5).
Recurrence of symptoms and ulcers is directly proportional to disease progression in patients with
systemic diseases complicated by vascular reactivity and Raynaud's phenomenon.
After DAS, an increase in digital temperatures (increased total flow) correlates with hemodynamically
insignificant occlusive disease and portends a good result.
However, patients without improvement in digital temperatures can experience significant benefits from
DAS.
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The recommendation to perform DAS only after an increase in digital temperatures following a digital
block biases patient selection to patients with potentially adequate arterial perfusion compromised by
vasospasm and/or arteriovenous shunting and portends a good to excellent postsurgical result. These
patients rarely have ulcers, and their DBIs are generally > 0.7. Patients who need DAS the least will have
the best outcomes. After DAS, many patients will improve with regard to symptoms and function, have a
significant decrease in the frequency of Raynaud's symptoms, and experience healing of refractory ulcers
without an increase in digital temperatures (2).
There are few studies evaluating the intermediate or long-term outcomes following DAS
(7,12,13,17,18,22). Studies are complicated by the heterogenicity of patients with collagen vascular
disease who have varying degrees of occlusive disease.
Most, but not all, ulcers heal following DAS.
Frequency of Raynaud's attacks decreases.
Long-term prognosis depends upon disease progression.
Additional occlusive episodes produce additional symptoms.
Atherosclerotic Disease/Calcific Arteritis (2,13,17,19)
Digital artery sympathectomy is ineffective in most patients with thrombosis secondary to atherosclerosis
from Buerger's disease unless there is evidence of a reversible vasospastic component as evidenced by:
Vasodilation after administration of intra-arterial medications (e.g., nitroglycerin, Priscoline).
Increased perfusion and temperature and/or improved laser Doppler flow after a sympathetic
intervention.
Although one study reports effectiveness in Buerger's patients, this result has not been our experience.
Digital artery sympathectomy is ineffective in patients with (a) thrombosis secondary to peripheral
vascular disease related to chronic renal failure (with calcific arteritis), (b) active inflammatory arteritis,
and (c) atherosclerosis associated with diabetes mellitus.
REFERENCES
1. Koman LA, Smith BP, Pollock F, et al.: The microcirculatory effects of peripheral sympathectomy. J Hand
Surg Am 5: 709-717, 1995.
2. Koman LA, Smith BP, Smith TL, et al.: Vascular disorders. In: Wolfe, Hotchkiss.
3. Maricq H: The microcirculation in scleroderma and allied diseases. Adv Microcirc 10: 17-52, 1982.
4. Ostergren J, Fagrell B: Videophotometric capillaroscopy for evaluating drug effects on skin microcirculation
—a doubleblind study with nifedipine. Clin Physiol 4: 169-176, 1984.
5. Ruch DS, Smith TL, Smith BP, et al.: Anatomic and physiologic evaluation of upper extremity ischemia.
Microsurgery 19(4): 181-188, 1999.
6. Koman LA, Smith TL, Smith BP, et al.: Arterial reconstruction in the ischemic hand and wrist: effects on
microvascular physiology and health-related quality of life. Am Soc Surg Hand 19(3): 829, 1996.
7. Flatt AE: Digital artery sympathectomy. J Hand Surg Am 6: 550-556, 1980.
8. Jones NF: Ischemia of the hand in systemic disease. Clin Plast Surg 16: 547-556, 1989.
9. Roos DB: Plethysmography: a simple method of studying and following peripheral vascular disorders. Surg
Clin North Am 49(6): 1333-1342, 1969.
10. Troum SJ, Smith TL, Koman LA, et al.: Management of vasospastic disorders of the hand. Clin Plast
Surg 24: 121-132, 1997.
11. Wilgis EFS: Digital sympathectomy for vascular insufficiency. Hand Clin 1: 361-367, 1985.
12. El-Gammal TA, Blair WF: Digital periarterial sympathectomy for ischaemic digital pain and ulcers. J Hand
Surg Br 16: 382-385, 1991.
13. Hartzell TL, Makhni EC, Sampson C: Long-term results of periarterial sympathectomy. J Hand Surg [Am]
34(8): 1454-1460, 2009.
14. Jones NF: Acute and chronic ischemia of the hand: pathophysiology, treatment, and prognosis. J Hand
Surg Am 16: 1074-1083, 1991.
15. Merritt WH: Comprehensive management of Raynaud's syndrome. Clin Plast Surg 24(1): 133-159, 1997.
16. Miller LM, Morgan RF: Vasospastic disorders, etiology, recognition, and treatment. Hand Clin 9(1): 171-
187, 1993.
17. Murata K, Omokawa S, Kobata Y, et al.: Long-term follow-up of periarterial sympathectomy for chronic
digital ischaemia. J Hand Surg Eur Vol 37(8): 788-793, 2012.
18. Ruch DS, Holden M, Smith BP, et al.: Periarterial sympathectomy in scleroderma patients: intermediate-
term follow-up. J Hand Surg [Am] 27(2): 258-264, 2002.
19. Savvidou C, Tsai TM: Long-term results of arterial sympathectomy and artery reconstruction with vein
bypass technique as a salvage procedure for severe digital ischemia. Ann Plast Surg 70(2): 168-171, 2013.
20. Stucker M, Quinna S, Memmel U, et al.: Macroangiopathy of the upper extremities in progressive
systemic sclerosis. Eur J Med Res 5(7): 295-302, 2000.
21. Taylor MH, McFadden JA, Bolster MB, et al.: Ulnar artery involvement in systemic sclerosis
(scleroderma). J Rheumatol 29(1): 102-106, 2002.
22. Ward WA, Moore AV: Management of finger ulcers in scleroderma. J Hand Surg Am 20(5): 868-872,
1995.
23. Koman LA, Nunley J, Goldner J, et al.: Isolated cold stress testing in the assessment of symptoms in the
upper extremity: preliminary communication. J Hand Surg Am 3: 305-313, 1984.
24. Koman LA, Smith BP, Smith TL: Stress testing in the evaluation of upper extremity perfusion. Hand Clin
1: 59-83, 1993.
25. Pollock FE Jr, Koman LA, Smith BP, et al.: Measurement of hand microvascular blood flow with isolated
cold stress testing and laser Doppler fluxmetry. J Hand Surg Am 18(1): 143-150, 1993.
Chapter 32
Operative Treatment of Selected Fractures of the Child's Hand
Julie Balch Samora
Donald S. Bae
Peter M. Waters
INTRODUCTION
Children and adolescents use their hands to explore the environment, to play, and to participate in sports
activities. For these reasons, fractures of the hand are common in skeletally-immature patients (1,2,3,4). While
most hand fractures in children can be managed nonoperatively, a small percentage of hand injuries account for
the majority of unfavorable outcomes (1,2,5,6). These fractures require careful surgical treatment to promote
optimal healing, improve appearance, and prevent long-term functional compromise.
Several principles germinal to the care of skeletally-immature patients should be followed (7,8). First, unique
characteristics of the physis must be understood (9). Physeal fractures constitute
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approximately one-third of pediatric hand fractures (1). Although children have the advantage of bony remodeling
with growth, maximal remodeling occurs in the plane of joint motion. Furthermore, the remodeling potential is
greater in younger patients and in fractures located adjacent to the physis. Conversely, intra-articular injuries
and coronal or rotational deformities have little remodeling potential (1,6,8). Surgical approaches and fracture
fixation, when possible, should not violate the physis to avoid the complications of growth disturbance. This is
typically accomplished with periosteal sutures; fine, smooth wires; or internal fixation that does not cross the
growth plate.
The small size of structures in the child's hand presents another challenge. Given the generous amount of
subcutaneous soft tissue, deformity may be more subtle and palpation and reduction maneuvers less precise.
Furthermore, the tissue available for fixation or repair is more tenuous than in adults. Smaller implants are
indicated, and smooth wires are used most often in order to carefully treat the small skeletal structures and avoid
physeal damage.
Finally, postoperative mobilization must be more restrictive in children, who may not comply with postoperative
activity restrictions. Casts are more frequently utilized, with incorporation of adjacent fingers, the whole hand,
wrist, and/or the elbow to prevent the loss of immobilization and/or secondary displacement. Postoperative
stiffness is not as prevalent as in adults, and with proper surgical techniques, fracture nonunion is rare.
Rather than provide a comprehensive review of pediatric hand fractures, this chapter will focus on four specific
injuries in the skeletally-immature hand requiring surgical treatment. Emphasis will be placed on surgical
technique, postoperative care, and the avoidance of complications. Throughout the discussion, underlying
principles of fracture care in the pediatric patient population will be highlighted.
SALTER-HARRIS III FRACTURE OF THE PROXIMAL PHALANX OF THE

THUMB
Salter-Harris III fractures are intra-articular and usually not amenable to closed reduction (Fig. 32-1). Salter-
Harris III fractures of the proximal phalanx of the thumb represent the pediatric equivalent of the adult
“gamekeeper's thumb” (6,10,11,12). Given the strength of the ulnar collateral ligament relative to the physis, a
radially directed force to the metacarpophalangeal (MCP) joint will typically result in an avulsion fracture of the
proximal phalangeal epiphysis (11). Displaced Salter-Harris III fractures of the proximal phalanx of the thumb
require open reduction and internal fixation to restore articular congruity, joint stability, and physeal alignment
(6).
FIGURE 32-1 Salter-Harris classification of physeal fractures.
Patients and/or parents will describe a radially directed force imparted to the thumb, typically during sports
participation or a fall. Physical examination reveals tenderness and swelling at the ulnar base of the proximal
phalanx. Laxity with careful radial stress may be elicited. Gentle examination techniques are required in the acute
setting, particularly in the younger, anxious child. Plain anteroposterior (AP) and lateral radiographs of the thumb
will confirm the diagnosis. In cases in which there is laxity with radial stress and negative radiographs, one can
conclude that there has been an injury to the ulnar collateral ligament of the thumb MCP joint. MRI scan should
be confirmatory.
Technique
Patients are positioned supine with the affected extremity placed on a radiolucent hand table (Fig. 32-2). A well-
padded tourniquet is placed on the upper brachium, and the entire extremity is prepped and draped after the
induction of general anesthesia. Regional anesthesia may be utilized as appropriate. The limb is exsanguinated
with an Esmarch bandage, and the tourniquet is raised to
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250 mm Hg. An incision is made over the dorsal-ulnar aspect of the thumb MCP joint (Fig. 32-3). Subcutaneous
dissection is performed in line with the skin incision, protecting the radial sensory nerve. The adductor pollicis
fascia is released from its insertion on the extensor tendon. As the ulnar collateral ligament is usually intact, the
MCP joint should be exposed distally through the fracture site. The ligament should not be divided.
After cleaning and irrigating the fracture site, the avulsed epiphyseal fracture fragment is carefully reduced. Two
parallel or slightly divergent smooth K-wires are placed into the reduced epiphyseal
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fragment, across the fracture site, and into the opposite radial cortex. Intraoperative fluoroscopy is helpful to
confirm anatomic reduction and appropriate placement of the wires (Fig. 32-3). If the ulnar collateral ligament is
noted to be lax or avulsed, its insertion may be advanced or repaired with fine absorbable sutures to the
underlying periosteum. The tourniquet is released and adequate hemostasis achieved. We prefer to bend and
cut the wires superficial to the skin. A layered closure is performed, carefully reapproximating the adductor
pollicis fascia. Care must be made to avoid suturing the extensor mechanism to the underlying joint capsule,
which may interfere with thumb flexion. The skin is closed with 4-0 absorbable suture in a subcuticular fashion. A
bulky dressing and thumb spica cast is then applied and usually bivalved.
FIGURE 32-2 Intraoperative positioning of the patient. The entire upper extremity is prepped and draped after
application of an upper extremity pneumatic tourniquet. A radiolucent arm table is utilized; alternatively, the
collecting plate of a fluoroscopy unit may be used to support the limb in very young patients.
FIGURE 32-3 Salter-Harris III fracture of the proximal phalanx of the thumb. A: Preoperative radiograph
demonstrating a displaced Salter-Harris III fracture of the proximal phalanx of the thumb. B: Planned surgical
incision over the dorsal-ulnar aspect of the thumb MCP joint.
FIGURE 32-3 (Continued ) C: Superficial exposure of the adductor fascia, held in forceps, and the extensor
mechanism, exposed by a retractor. D: Displaced fracture fragment. Note the intact ulnar collateral ligament,
held by forceps. E: Postoperative radiographs demonstrating anatomic reduction and pin fixation.
Pearls and Pitfalls

If better visualization of the articular surface is necessary, the dorsal capsule may be incised.
Be certain to restore anatomic alignment to the joint and stability to the fragment.
Do not detach the UCL.
Patients remain in the thumb spica cast for 4 to 6 weeks until radiographic evidence of fracture healing. After this
time, the cast is discontinued and the smooth wires are removed, usually in the office setting without the need for
anesthesia. Range-of-motion and strengthening exercises are begun with a home program. A protective splint for
potential traumatic activities is utilized until full motion and strength are achieved, which generally occurs by 8 to
12 weeks postoperatively. At that time, unrestricted activities are performed.
Complications
Failure of diagnosis or inadequate treatment may result in premature epiphyseal closure, nonunion, and an
incongruent or unstable joint, all of which may lead to pain and limitations of strength, motion, and function
(6). Angular deformity, nonunion, MCP joint instability, and posttraumatic arthrosis are risks of nonoperative
treatment of a displaced fracture. In the absence of MCP joint arthrosis, nonunions may be treated with
open reduction, bone grafting,
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and internal fixation. Small fracture fragments may be excised with ulnar collateral ligament advancement
and repair. Persistent instability secondary to ligamentous injury is treated with ulnar collateral ligament
reconstruction. In the setting of arthrosis, MCP joint arthrodesis may be used as a salvage procedure.
Results
With prompt diagnosis and appropriate treatment using the techniques described here, patients may expect
full recovery of thumb MCP range of motion and stability. To our knowledge, there have been no peer-
reviewed publications reporting the results of surgical treatment of Salter-Harris III fractures of the proximal
phalanx of the thumb. However, our experience with this technique has been universally successful, with
patients returning to activities as tolerated.
PHALANGEAL NECK FRACTURE

Phalangeal neck fractures, also referred to as subcapital or subcondylar fractures, almost exclusively occur in
children often due to a crush injury from a closing door (5,6,13,14,15). Far less commonly, these fractures can
occur in young athletes. The distal fragment is often rotated and displaced in extension as the patient attempts to
draw the hand away. Both the middle and the proximal phalanx can be involved, and the border digits are most
affected (2,4). As the phalangeal condyles are not completely ossified in younger patients, these injuries often
present with innocuous-appearing radiographs, sometimes characterized as only a small fleck or “cap” of bone.
For this reason, a high index of suspicion must be maintained and radiographs carefully reviewed to prevent
missed diagnoses (2).
Al-Qattan (15) classified these fractures into three types: Type I are nondisplaced, type II are displaced with
some bone-to-bone contact, and type III are completely displaced without any bony apposition (Fig. 32-4). Type II
and III fractures are unstable injuries, are prone to
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nonunion, and are at high risk for secondary displacement after closed reduction alone (15,16). These fractures
should be treated with closed reduction and pin fixation. Open reduction is less often needed and carries
increased risk of avascular necrosis if too much soft-tissue dissection occurs.
FIGURE 32-4 Classification of phalangeal neck fractures. (From Al-Qattan MM: Phalangeal neck fractures in
children: classification and outcome in 66 cases. J Hand Surg 26B: 112-121, 2001.)
Patients with phalangeal neck fractures present with pain and limited motion after a crush and withdrawal injury.
AP radiographs of the hand may demonstrate subtle findings, and a true lateral radiograph of the affected digit is
critical to make the correct diagnosis and assess for rotational deformity (13) (Fig. 32-5). Oblique radiographs
may be the most helpful views to demonstrate or characterize this pattern of injury.
FIGURE 32-5 Phalangeal neck fracture. A: Preoperative AP and lateral radiographs demonstrating a displaced
phalangeal neck fracture of the ring finger middle phalanx. B: Intraoperative AP and lateral radiographs
demonstrating anatomic reduction and percutaneous pin fixation.
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Technique
Patients are positioned, prepped, and draped as previously described. Closed reduction is performed with
longitudinal distraction, followed by hyperflexion of the involved interphalangeal (IP) joint and volar-directed
pressure on the distal fracture fragment. Radial-ulnar angulation and malrotation are corrected at the same time.
With fluoroscopic guidance maintaining the involved IP joint in flexion, crossed, or a single oblique (in the very
young), K-wires (usually 0.035 in.) are inserted distal to proximal at the collateral recesses and passed across
the fracture site, engaging the opposite cortex. K-wires should not cross at the fracture site (Fig. 32-5). Careful
attention is made not to pass wires through the proximal articular surface or physis. Wire placement and fracture
stability are confirmed fluoroscopically. Once adequate reduction and fixation are confirmed, the wires are
trimmed and left protruding through the skin. The hand is immobilized in a cast extending to the fingertips.
If adequate reduction cannot be achieved by closed manipulation, open reduction should be performed. We
prefer a midaxial or dorsal approach, mobilizing the lateral bands volarly and the extensor mechanism dorsally, to
gain access to the phalangeal neck. Soft-tissue attachments to the fracture fragment are preserved to prevent
disruption of the vascular supply and subsequent osteonecrosis. Once the reduction is performed, percutaneous
pinning and cast immobilization may be performed as described above.
Pearls and Pitfalls

A high index of suspicion is necessary to diagnose these injuries. A true lateral radiograph of the affected digit
is a prerequisite.
It is important not to cross the pins at the fracture site.
The starting point is more distal than is usually expected, and being certain there is distal pin placement for
stable pin fixation is critical to success.
It is important to maintain ligamentous attachments, avoid excessive manipulation, and minimize trauma to the
articular fragment during the reduction, especially if by open techniques, and passage of K-wires.
Percutaneous pin osteoclasis may be performed in late-presenting fractures with nascent malunions if the
fracture is still radiographically visible.
Patients are casted until 4 weeks postoperatively, at which time the K-wires are removed and gentle range-of-
motion exercises are begun. It is important to maintain fixation for 4 weeks, as premature K-wire removal may
predispose to secondary displacement (6,12).
Complications
Loss of motion is a common complication of phalangeal neck fractures in the skeletally-immature patient
(15). This is usually secondary to late presentation with either an incipient or established dorsal malunion
and bony formation within the subcondylar fossa (Fig. 32-6). If detected before the fracture has completely
united in a malrotated or displaced position, percutaneous pin osteoclasis may be performed. A smooth wire
is inserted percutaneously into the fracture site through the fracture callus under fluoroscopic guidance. If
malunion has occurred, patients may require a subcondylar fossa reconstruction to regain IP flexion (14).
However, in the young patient, remodeling of phalangeal neck fracture extension malunions has occurred
over the course of 1 to 2 years postinjury (16).
Loss of extension may also occur, particularly with dorsal approaches, if the extensor mechanism is not
carefully handled and preserved. Redisplacement can also occur, especially when closed reduction alone
or poor pin fixation is used (6).
Nonunion has been reported, with risk factors being younger age (with incomplete ossification of condyles),
displaced fractures, poor lateral radiographs, inadequate initial management, delay of K-wire fixation of 3
weeks or more, and premature removal of K-wires (12).
Osteonecrosis of the phalangeal head is another potential complication. The distal fracture fragment is
small, can be predominantly cartilaginous, and has a tenuous blood supply.
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FIGURE 32-6 Phalangeal neck fracture malunion. A: Lateral radiograph demonstrating a proximal
phalangeal neck fracture malunion with significant bony formation within the subcondylar fossa. B: Lateral
radiograph after subcondylar fossa reconstruction.
Results
With prompt diagnosis and appropriate treatment, patients may expect almost universal fracture healing and
good to excellent functional results. Our results are consistent with those reported by Al-Qattan and others
(6,15,17). Timely treatment, anatomic reduction of fracture fragments, and secure fixation and cast
immobilization for 4 weeks are keys to achieving good functional results.
EXTRAPHYSEAL PHALANGEAL FRACTURE

Extraphyseal fractures of the phalanges are not as common as physeal fractures (1,5,6,18). The fracture pattern
and forces imparted by the adjacent musculotendinous units dictate the subsequent deformity and displacement.
In general, up to 20 degrees of angulation in the plane of digital motion may remodel with growth, although this is
dependent upon patient age and fracture location in terms of proximity to the physis. Coronal and rotational
displacements, however, have poor remodeling potential (1). Furthermore, small fracture fragment size and
interposed periosteum and/or soft tissue may preclude successful closed reduction. For these reasons,
extraphyseal phalangeal fractures with greater than 20 degrees of sagittal angulation or any coronal or rotational
displacement should be reduced and internally stabilized.
Patients will typically present with pain, swelling, ecchymosis, and limited motion. Careful examination of the
plane of the fingernails or cascade with digital flexion or wrist tenodesis may reveal malrotation. Every displaced
phalangeal fracture should be assessed clinically for malrotation. Comparison of tenodesis rotational alignment
to the contralateral side is required. Plain AP and lateral radiographs will confirm the diagnosis and provide
further information regarding displacement, angulation, and/or rotation (Fig. 32-7). Spiral-oblique fractures are
particularly prone to coronal and rotational malalignment. Oblique radiographs of the affected digits are often
helpful in subtle injuries.
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FIGURE 32-7 Extraphyseal fracture of the proximal phalanx of the thumb. A: Injury radiographs demonstrating a
proximal phalangeal fracture of the thumb with apex volar angulation. Despite attempted closed reduction, there
was persistent fracture instability and unacceptable angulation in the sagittal plane. B: Intraoperative
radiographs demonstrating anatomic reduction with fixation using percutaneous K-wires.
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Technique
After the induction of adequate anesthesia, patients are positioned, prepped, and draped as described above.
Closed reduction is performed with longitudinal traction and exaggeration of the deformity, followed by correction
of the angular and/or rotational deformity. In proximal phalangeal injuries, flexion of the MCP joint will aid in
reduction by stabilizing the proximal fracture fragment and relaxing the deforming force of the intrinsic
musculature. The reduction is confirmed by clinical inspection and fluoroscopy. Fracture stabilization is then
achieved with percutaneous K-wires placed in the midaxial line (Fig. 32-7). Ideally, the smooth wires are placed
orthogonal to the fracture line. Crossed wire fixation may be required in predominantly transverse fracture
patterns. Wires are left superficial to the skin, and the hand is immobilized in a cast extending beyond the
fingertips.
Open reduction is performed when closed reduction is unsuccessful, as may occur with soft-tissue or periosteal
interposition as well as unstable intra-articular fractures. For fractures involving the proximal two-thirds of the
proximal phalanx, a dorsal tendon splitting approach is preferred. In fractures of the distal one-third of the
proximal phalanx or distally, open reduction may be performed by elevating the lateral bands and/or mobilizing
the extensor mechanism to gain access to the zone of injury. The fracture is reduced and assessed with
fluoroscopy. Smooth K-wire fixation is then performed as previously described. In older patients with large
fracture fragments, internal fixation using interfragmentary compression screws with or without neutralization
plates may be considered.
Pearls and Pitfalls

In proximal phalangeal injuries, flex the MCP joint to stabilize the proximal fracture fragment and relax the
deforming forces to aid in reduction and pinning.
Failure to recognize and treat a malrotated fracture should be avoided.
More extensive internal fixation such as plates and screws carries increased risk of extensor mechanism
contracture postoperatively.
Casts are discontinued at 3 to 4 weeks postoperatively and wires are removed. Gentle range-ofmotion exercises
are initiated at this time. Injuries adjacent to the proximal IP joint are particularly at risk for permanent stiffness,
emphasizing the need for early or frequent motion once the fracture is healed. Patients are allowed to return to
full activities at 6 to 8 weeks postoperatively. Formal physical or occupational therapy is rarely required.
Results/Complications
With prompt diagnosis and timely surgery, patients may expect almost universal fracture healing and restoration
of full function. Complications of redisplacement, stiffness, and persistent deformity may be avoided by
expeditious treatment, meticulous surgery, and appropriate postoperative immobilization. In rare instances of
malunion with persistent deformity and/or functional compromise, corrective osteotomy may be performed.
Typically, this may be performed at the basilar metaphysis, which is technically less challenging and provides for
adequate correction.
SEYMOUR FRACTURE
“Seymour fractures” are extra-articular transverse fractures of the base of the distal phalanx associated with a
nail bed laceration often seen in children (Fig. 32-8A) (19,20). The mechanism of injury is often entrapment of the
digit in a closing door or swing, with the long finger most commonly affected (19). Interposed germinal matrix
often occurs within the displaced fracture. Because this is an open fracture, treatment should include nail plate
removal, irrigation and debridement of the fracture, removal of soft tissue, open reduction of the physeal fracture,
and nail bed repair.
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FIGURE 32-8 A: Lateral radiograph demonstrating an extra-articular transverse fracture of the base of the distal
phalanx (classic Seymour fracture). B: Intraoperative photograph of surgical exposure with care to protect soft
tissues. (From Waters PM, Bae DS: Pediatric hand and upper limb surgery. A practical guide. Philadelphia, PA:
It is important not to miss these open injuries. Physical examination reveals tenderness and swelling around the
base of the distal phalanx and a mallet-like deformity with the base of the nail plate lying superficial to the
proximal nail fold. Plain AP and lateral radiographs will confirm the diagnosis. Mallet fingers occur with disruption
at the epiphyseal insertion of the terminal tendon; Seymour fractures occur with displacement through the more
distal physis.
Technique
This may be performed in the emergency room setting under local anesthesia or in the formal operating suite.
Patients are positioned supine with the affected extremity placed on a hand table. A digital tourniquet may be
utilized, but be very careful not to forget this and discharge the patient home with the tourniquet still in place;
using a large clamp to hold the elastic tourniquet will increase your awareness and lessen the risk of an
avascular digit with prolonged tourniquet. After nail plate removal, incisions in the dorsal skin are made from both
angles of the dorsal nail fold proximally and obliquely toward the distal IP joint extension crease (Fig. 32-8B).
Skin flaps are then raised with care taken to protect the dorsal nail fold. The germinal matrix and nail bed injury
can then be clearly visualized. Hyperflex through the fracture site to identify the fracture and extract the
interposed matrix and nail fold (1). Fully irrigate and debride the fracture site and then reduce under direct
visualization. A retrograde percutaneous longitudinal K-wire may be utilized if needed for stabilization. Another
option is to replace the trephinated nail plate beneath the dorsal nail fold after nail bed repair, which provides
bony stabilization. The nail bed is repaired utilizing interrupted 6-0 Chromic sutures. The back cuts in the dorsal
nail fold are closed with interrupted 5-0 Chromic sutures. We place sterile dressings followed by a hand-based
cast.
Pearls and Pitfalls

One may utilize outside-in horizontal mattress sutures through the eponychium, grasping the proximal germinal
matrix and pulling it under the dorsal hood when repairing the nail bed laceration.
Visualize the fracture site directly to ensure all interposed tissue is removed.
If one chooses not to place a K-wire for fixation, immobilize the distal phalanx in extension and obtain weekly
radiographs to assess for maintenance of reduction.
Do not misinterpret a Seymour fracture to be a mallet finger injury. Treatment of an open Seymour fracture
with a splint can lead to osteomyelitis.
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Patients should be up to date with their tetanus prophylaxis, should receive antibiotics upon diagnosis of the
injury, and should be treated with 5 days of oral antibiotics. The pin may be removed in 3 to 4 weeks at the time
of cast removal and range-of-motion exercises initiated.
Complications/Results
Failure of diagnosis or inadequate treatment may result in infection, persistent flexion deformity, nail plate
deformity, physeal arrest, dorsal rotation of the epiphysis, and chronic osteomyelitis (1,15,21,22). Infection as
well as flexion deformities of 10 to 15 degrees are not uncommon (1,19).
REFERENCES
1. Barton NJ: Fractures of the phalanges of the hand in children. Hand 11: 134-143, 1979.
2. Hastings H II, Simmons BP: Hand fractures in children. A statistical analysis. Clin Orthop Relat Res 188:
120-130, 1984.
3. Bhende MS, Dandrea LA, Davis HW: Hand injuries in children presenting to a pediatric emergency
department. Ann Emerg Med 22: 1519-1523, 1993.
4. Rajesh A, Basu AK, Vaidhyanath R, et al.: Hand fractures: a study of their site and type in childhood. Clin
Radiol 56: 667-669, 2001.
5. Leonard MH, Dubravcik P: Management of fractured fingers in the child. Clin Orthop Relat Res 73: 160-
168, 1970.
6. Fischer MD, McElfresh EC: Physeal and periphyseal injuries of the hand. Patterns of injury and results of
treatment. Hand Clin 10: 287-301, 1994.
7. Stein F: Skeletal injuries of the hand in children. Clin Plast Surg 8: 65-81, 1981.
8. Wilkins KE: Principles of fracture remodeling in children. Injury 36(Suppl 1): A3-A11, 2005.
9. Salter RB, Harris WR: Injuries involving the epiphyseal plate. J Bone Joint Surg Am 45: 587-622, 1963.
10. Davies MB, Wright JE, Edwards MS: True skier's thumb in childhood. Injury 33: 186-187, 2002.
11. Gabuzda G, Mara J: Bony gamekeeper's thumb in a skeletally immature girl. Orthopedics 14: 792-793,
1991.
12. Al-Qattan MM, Cardoso E, Hassanain J, et al.: Nonunion following subcapital (neck) fractures of the
proximal phalanx of the thumb in children. J Hand Surg Br 24: 693-698, 1999.
13. Dixon GL Jr, Moon NF: Rotational supracondylar fractures of the proximal phalanx in children. Clin
Orthop Relat Res 83: 151-156, 1972.
14. Simmons BP, Peters TT: Subcondylar fossa reconstruction for malunion of fractures of the proximal
phalanx in children. J Hand Surg Am 12: 1079-1082, 1987.
15. Al-Qattan MM: Phalangeal neck fractures in children: classification and outcome in 66 cases. J Hand
Surg Br 26: 112-121, 2001.
16. Cornwall R, Waters PM: Remodeling of phalangeal neck fracture malunions in children: case report. J
Hand Surg Am 29: 458-461, 2004.
17. Matzon JL, Cornwall R: A stepwise algorithm for surgical treatment of type II displaced pediatric
phalangeal neck fractures. J Hand Surg Am 39: 467-473, 2014.
18. De Jonge JJ, Kingma J, van der Lei B, et al.: Phalangeal fractures of the hand. An analysis of gender and
age-related incidence and aetiology. J Hand Surg Br 19: 168-170, 1994.
19. Al-Qattan MM: Extra-articular transverse fractures of the base of the distal phalanx (Seymour's fracture)
in children and adults. J Hand Surg Br 26: 201-206, 2001.
20. Seymour N: Juxta-epiphysial fracture of the terminal phalanx of the finger. J Bone Joint Surg Br 48: 347-
349, 1966.
21. Ganayem M, Edelson G: Base of distal phalanx fracture in children: a mallet finger mimic. J Pediatr
Orthop 25: 487-489, 2005.
22. Waters PM, Benson LS: Dislocation of the distal phalanx epiphysis in toddlers. J Hand Surg Am 18: 581-
585, 1993.
Chapter 33
Reconstruction of Type II/IIIa Thumb Hypoplasia
Joshua M. Abzug
Scott H. Kozin
INTRODUCTION
Thumb hypoplasia encompasses a wide spectrum of presentations from thumbs that have minimal hypoplasia to
thumbs with complete absence. As thumb hypoplasia is part of the continuum of radial deficiency, it is important
to perform a workup of associated entities such as thrombocytopenia absent radius (TAR) syndrome, Fanconi
anemia (FA), Holt-Oram syndrome, CHARGE syndrome, and VACTERL association (1) (Table 33-1). Due to the
wide variation in presentation, a variety of treatment options exist based on the classification of the hypoplastic
thumb.
Classification of thumb hypoplasia is most commonly applied utilizing the Blauth classification, which is an
expansion of Muller's original classification (2,3). The focus of this chapter will be on the diagnosis and treatment
of type II and IIIa thumbs, which are the thumbs that can undergo reconstruction as opposed to pollicization
(Table 33-2). Both type II and type IIIa thumbs are hypoplastic with decreased size compared to a “normal”
thumb. Additionally, both types have absence of the intrinsic thumb musculature (Fig. 33-1), a narrow thumb-
index web space (Fig. 33-2), and ulnar collateral ligament (UCL) deficiency (Fig. 33-3). The UCL deficiency may
be due to a deficiency of the ligament or secondary to an anomalous connection between the flexor pollicis
longus (FPL) and extensor pollicis longus (EPL) tendons, known as a pollex abductus (4,5,6). The presence of a
pollex abductus leads to UCL insufficiency by attenuating the UCL over time and preventing active
interphalangeal (IP) joint motion. Release of the pollex abductus must be performed during UCL reconstruction,
when present.
In addition to the aforementioned features, type IIIa thumbs have extrinsic muscle and tendon abnormalities (7).
Additionally, skeletal deficiency may be present, but the thumb carpometacarpal (CMC) joint remains stable. The
extrinsic tendon abnormalities may involve the extensor side, with an absent or hypolastic EPL or extensor
pollicis brevis, or the flexor side, with an absent or hypoplastic FPL. These deficiencies are manifested as
decreased or absent thumb IP joint motion. Additional anomalies may include tendon adhesions, tendon
duplications, abnormal tendon or muscle routes, abnormal insertions, absent tendons, or underdeveloped pulleys
(8,9,10,11,12).
Treatment of type II and IIIa thumbs is aimed at correcting the thumb hypoplasia utilizing a combination of
procedures to address the functional limitations. The stability provided by the ligamentous structures of the
thumb, in particular the UCL, is imperative to permitting the use of the thumb as a stable post during pinch and
grasp. Reconstruction of the UCL will provide the necessary
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stability to perform these functions. However, the presence of bidirectional or global instability may be best
treated by reconstruction of the radial and UCL or preferably with a chondrodesis of the metacarpophalangeal
(MCP) joint to achieve firm stability and provide a stable fulcrum. Opposition of the thumb is critical during grasp
activities and can be achieved by performance of an opponensplasty. Lastly, deepening of the thumb-index web
space is important to permit acquisition of large objects during grasp (Fig. 33-4). This involves rearrangement of
the skin as well as deeper soft-tissue release.
TABLE 33-1 Conditions Commonly Associated with Thumb Hypoplasia
Condition Features in Addition to the Thumb Hypoplasia
CHARGE syndrome Coloboma of the eye, Heart defects, Atresia of th nasal choanae, Retardation
of growth and/or development, Genital and/or urinary abnormalities, Ear
abnormalities and deafness
Fanconi anemia Aplastic anemia that develops in childhood, typically around 6 y of age
Holt-Oram syndrome Cardiac anomalies, typically septal defects
Thrombocytopenia Thrombocytopenia that is initially present at birth and improves over time
and absent radius
(TAR) syndrome
VACTERL association Vertebral anomalies, Anal atresia, Cardiac anomalies, Tracheoesophageal

fistula, Esophageal atresia, Renal anomalies/Radial dysplasia, Lower limb
abnormalities
TABLE 33-2 Classification of Thumb Hypoplasia and Treatment
Thumb Type Characteristics Treatment
I Minor generalized hypoplasia Observation
II 1. Absence of intrinsic thenar musculature 1. Opponensplasty

2. First web space narrowing 2. First web space deepening
3. Ulnar collateral ligament (UCL) insufficiency 3. UCL reconstruction
IIIA 1. Features of a type II thumb Reconstruction

2. Extrinsic tendon and muscle abnormalities
3. Skeletal deficiency with a stable CMC joint
IIIB 1. Features of a type II thumb Pollicization

2. Extrinsic tendon and muscle abnormalities
3. Skeletal deficiency with an unstable CMC joint
IV “Pouce flottant” Pollicization
V Absent thumb Pollicization

FIGURE 33-1 Absence of the thumb intrinsic musculature in a 2-year-old with type II left thumb hypoplasia.
(Courtesy of Shriners Hospital for Children, Philadelphia, PA.)
FIGURE 33-2 Narrowed first web space in a 2-year-old with type II left thumb hypoplasia. (Courtesy of Shriners
Hospital for Children, Philadelphia, PA.)
FIGURE 33-3 Ulnar collateral ligament insufficiency in a 2-year-old with type II left thumb hypoplasia. Note the
presence of carpometacarpal (CMC) stability. (Courtesy of Shriners Hospital for Children, Philadelphia, PA.)
During reconstruction of type IIIa hypoplastic thumbs, additional procedures may be necessary such as the
division of anomalous tendon interconnections, rerouting of extrinsic tendons, or pulley reconstruction. Tendon
transfers including a ring finger flexor digitorum superficialis (FDS) to FPL or extensor indicis proprius (EIP) to
EPL may help to restore the function of thumb IP joint flexion and extension, respectively (13). These procedures
are complicated by the lack of pulleys and deficiency of the entire flexor sheath. Hence, we focus our surgical
reconstruction of the intrinsic abnormalities and often ignore the extrinsic deficiencies.
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FIGURE 33-4 A 10-year-old child status post left thumb-index web space deepening and flexor digitorum
superficialis tendon opposition transfer. A: The ability to acquire a large object is now present. B: Opposition to
the small finger. Note the scars present in the thumb-index web space. (Courtesy of Shriners Hospital for
Children, Philadelphia, PA.)
INDICATIONS
There is little role for nonoperative management of type II and IIIa hypoplastic thumbs. A thumb spica splint
can be utilized to provide stability to an unstable MCP joint; however, the splint often limits function due to
its bulkiness and need to prevent motion. Therefore, the absence of intrinsic thumb musculature and the
presence of MCP joint instability is an indication for operative reconstruction to provide stability to the thumb
and to enhance pinch and grasp. Additionally, a narrowed thumb-index web space should be addressed to
permit easier acquisition of large objects (Fig. 33-4).
CONTRAINDICATIONS
The main contraindication to reconstruction of a hypoplastic thumb is a lack of stability at the CMC joint. In these
patients, a pollicization will yield superior results compared to tendon transfers, bone lengthening, and joint
stabilizations (14,15,16). A simple explanation to parents as to why a pollicization should be performed instead of
a reconstruction is that the procedure would be like “trying to build a house without a stable foundation.” An
additional contraindication to reconstruction of a type IIIA thumb is if the child is bypassing his or her thumb in
favor of scissor pinch, the index finger is pronating, and the index-long web space is widened. In this scenario,
pollicization
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is preferred. Lastly, reconstruction of a small hypoplastic thumb, even with a stable CMC joint, may provide
decreased function compared to pollicization of a mobile index finger (17). In these instances, a detailed and
thoughtful conversation is necessary with the parents discussing how “function trumps form.” Typically, parents
ultimately come to the conclusion that a pollicization will yield better function than reconstruction of a small,
poorly functioning thumb. As an option, parents are given the opportunity to talk to another parent of a child who
underwent a similar difficult decision.
The key to preoperative preparation is ensuring that the diagnosis is correct, that is, being able to differentiate
between a type IIIA (stable) and IIIB (unstable) thumb. This may require multiple examinations performed over
time. The involvement of a therapist can be instrumental as they can provide a second pair of “eyes” and often
can spend longer periods of time with the patient. Since the first metacarpal base and trapezium do not ossify
until about 6 years of age, radiographs are often not helpful in assessing for stability at the CMC joint. One
exception is when the metacarpal base tapers to a point as opposed to having the typical metaphyseal flare (Fig.
33-5). However, this radiographic finding is inconsistent. Advanced imaging modalities such as ultrasound or
magnetic resonance imaging (MRI) permit better visualization of the cartilaginous metacarpal base and trapezium
but can be challenging to interpret and/or require sedation.
As with any procedure, it is important to have the appropriate equipment available.
Minifluoroscopy unit
Pneumatic tourniquet
Basic hand set including extra Allis clamps (Jarit, Hawthorne, NY)
Kirschner wires with a drill
Casting material
If the child has an associated syndrome, it may be best to perform the procedure in a hospital with pediatrician
back up and/or have a pediatric anesthesiologist perform the case. This is especially true for VACTERL patients
that may have airway issues.
FIGURE 33-5 Posteroanterior (PA) radiograph of a 2-year-old child's hand demonstrating the tapering of the first
metacarpal to a point indicating an unstable carpometacarpal joint. (Courtesy of Shriners Hospital for Children,
Philadelphia, PA.)
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TECHNIQUE
Reconstruction of a type II or IIIA hypoplastic thumb includes performing a combined procedure made up of an
opponensplasty, a UCL reconstruction, and a first web space deepening (Video 33-1). Releasing a pollex
abductus should be performed, but we have not had good success performing tendon transfers for extrinsic
abnormalities. Therefore, the treatment of type II and IIIa hypoplastic thumbs is the same in our practices.
Persistent extrinsic functional deficits may be addressed at a second operation.
Video 33-1 Surgical technique video demonstrating treatment of a type II hypoplastic thumb with a thumb-index
web deepening, an opponensplasty, and UCL reconstruction. (Courtesy of Shriners Hospital for Children,
Philadelphia, PA.)
Despite numerous available donors for the opponensplasty, our preference is to perform a long or ring finger
FDS opposition transfer and utilize the tail end of the tendon to reconstruct the UCL. The FDS is preferred due to
its length, technical ease, power, expendability, and synergism. Additionally, we utilize a four-flap Z-plasty to
deepen the thumb-index web space and permit access to the deep structures that require release. The four-flap
Z-plasty lengthens the tight skin and provides a rounded contour in the first web space. During the deep soft-
tissue release, the investing fascia around the adductor pollicis is released while protecting the princeps pollicis
artery and its branches. If the web space is extremely tight, partial release of the adductor muscle and/or first
dorsal interosseous muscle is required.
The procedure is performed as follows:
Patient placed supine on the operating room table and general anesthesia induced.
Preoperative antibiotics administered.
Nonsterile pneumatic tourniquet applied.
Limb prepped and draped in usual sterile fashion.
Incisions carefully drawn (Fig. 33-6). The four-flap Z-plasty should have equal length limbs.
Limb exsanguinated and tourniquet inflated.
Four-flap Z-plasty incision performed. The radial limb may be extended in a proximal direction to expose the
UCL and the MCP joint if needed.
Deep investing fascia around adductor pollicis is released while protecting princeps pollicis artery and its
branches.
Partial release of the adductor muscle and/or first dorsal interosseous muscle performed as needed.
Short oblique incision made over the base of long or ring finger. The choice of which finger to use is made
based on which finger appears to have a stronger FDS tendon.
The long or ring finger FDS tendon is identified and separated from the flexor digitorum profundus (FDP)
tendon.
The FDS tendon is isolated with an Allis clamp (Jarit, Hawthorne, NY) or vessel loop.
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An oblique or zigzag incision is made over the ulnar portion of the volar forearm.
The long or ring finger FDS tendon is identified through this proximal incision and isolated with an Allis clamp
(Jarit, Hawthorne, NY) or vessel loop (Fig. 33-7).
Confirmation of having the same tendon is performed by twirling the Allis clamps (Jarit, Hawthorne, NY) and
seeing the tendon glide between them (Fig. 33-8).
The FDS tendon is tagged distally with a suture and cut just distal to the stitch.
By twirling the proximal Allis clamp (Jarit, Hawthorne, NY), the FDS tendon is rolled through the carpal tunnel
into the proximal forearm and brought out the proximal incision (Fig. 33-9).
FIGURE 33-6 Intraoperative photographs depicting the planned incisions necessary to perform reconstruction of
a type II or IIIA hypoplastic thumb. A: Incisions planned to obtain the ring finger FDS, create a pulley in the flexor
carpi ulnaris, and transfer the FDS to the thumb for opposition and to reconstruct the UCL. B: Thumb-index web
space deepening incision utilizing a four-flap Z-plasty. (Courtesy of Joshua M. Abzug, MD.)
FIGURE 33-7 Isolation of ring figure FDS in proximal wound. Note the flexion at the proximal interphalangeal joint
but extension at the distal interphalangeal joint. (Courtesy of Shriners Hospital for Children, Philadelphia, PA.)
FIGURE 33-8 Utilization of two Allis clamps to ensure isolation of the same tendon proximally and distally.
(Courtesy of Joshua M. Abzug, MD.)
FIGURE 33-9 FDS tendon rolled into volar forearm incision. (Courtesy of Shriners Hospital for Children,
Philadelphia, PA.)
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Failure of the FDS tendon to roll into forearm requires assessment for FDP-FDS attachments and/or division of
Camper's chiasm. The tag suture can be used to retrieve the tendon.
The flexor carpi ulnaris (FCU) tendon is now identified and isolated in the volar forearm wound.
The most distal 2 to 3 cm of FCU tendon is split longitudinally and the radial one-half of the FCU tendon is
harvested preserving the attachment to the pisiform (Fig. 33-10).
The radial one-half of the tendon is passed through the retained FCU at the pisiform to create a loop that will
act as the pulley for the opposition transfer (Fig. 33-11).
The cut portion is now sutured to the intact FCU at the level of the pisiform.
The loop is assessed to ensure enough space is present to create the pulley without inhibiting gliding of the
FDS tendon (Fig. 33-12).
The FDS tendon is now passed through the FCU loop (Fig. 33-13).
A midaxial incision is made over the radial aspect of the thumb in the region of the MP joint.
A subcutaneous tunnel is created between the volar forearm incision and the radial thumb incision to permit
the passage of the FDS tendon.
The tendon is passed through the subcutaneous tunnel and brought out the radial thumb incision (Fig. 33-14).
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Under fluoroscopic guidance, the metacarpal head is isolated and a 0.045” Kirschner wire is driven across the
metacarpal head parallel to the joint surface (Fig. 33-15). The wire should be driven from volar-radial to
dorsal-ulnar.
The hole is now enlarged with an appropriately sized drill bit to permit passage of the FDS tendon.
The MCP joint is reduced and stabilized with a 0.045” Kirschner wire drilled retrograde from the tip of the
thumb.
The FDS tendon is passed through the drill hole to the ulnar side of the thumb so it can be used for ligament
reconstruction (Fig. 33-16). Circumduction of the suture during passage may permit easier passage. If the
tendon is too large, one FDS slip can be removed to permit passage.
The FDS tendon is sutured to the periosteum on the radial side of the thumb once the correct tension is
present. The appropriate tension is assessed utilizing tenodesis to ensure that the thumb positions into
opposition (Fig. 33-17).
The remaining FDS tendon on the ulnar side of the thumb is sutured to the bone of the proximal phalanx to
reconstruct the UCL (Fig. 33-18).
Typically, enough FDS tendon is available to permit the tendon to be folded back on itself to perform a double-
stranded repair.
The wounds are irrigated and the incisions are closed with absorbable suture.
Following application of sterile dressings, the tourniquet is deflated and the thumb assessed to ensure
appropriate capillary refill is present.
A long arm thumb spica cast is applied.
FIGURE 33-10 One-half of the distal 2 to 3 cm of FCU is split longitudinally to construct a pulley for the FDS
tendon. (Courtesy of Shriners Hospital for Children, Philadelphia, PA.)
FIGURE 33-11 Passage of the cut end of the FCU through the intact ulnar one-half of the FCU tendon. A:
Creation of a longitudinal slit in the FCU with a straight tendon passer. B: Passage of the cut end of the FCU
tendon through the newly created longitudinal slit. (Courtesy of Joshua M. Abzug, MD.)
FIGURE 33-12 Assessment of the newly created pulley to ensure adequate space is available to permit gliding of
the FDS tendon. (Courtesy of Joshua M. Abzug, MD.)
FIGURE 33-13 Passage of the FDS tendon through the newly created FCU pulley. (Courtesy of Joshua M.
Abzug, MD.)
FIGURE 33-14 Passage of FDS tendon through the subcutaneous tunnel to the radial side of the thumb.
(Courtesy of Shriners Hospital for Children, Philadelphia, PA.)
FIGURE 33-15 Kirschner wire driven across metacarpal head parallel to joint surface. (Courtesy of Shriners
Hospital for Children, Philadelphia, PA.)
FIGURE 33-16 FDS tendon passed through metacarpal head to the ulnar side of the thumb. (Courtesy of
Shriners Hospital for Children, Philadelphia, PA.)
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FIGURE 33-17 Tenodesis utilized to assess tension of opposition transfer. (Courtesy of Joshua M. Abzug, MD.)
FIGURE 33-18 FDS tendon used to reconstruct the UCL. Note the longitudinal Kirschner wire exiting from the tip
of the thumb. (Courtesy of Shriners Hospital for Children, Philadelphia, PA.)
PEARLS AND PITFALLS

It is imperative to obtain an accurate assessment regarding the stability of the thumb CMC joint. Pearls include
performing multiple examinations as necessary and enlisting a therapist to aid in the assessment.
Ensure the patient is a good candidate for reconstruction. Poor candidates include those patients who bypass
the thumb by scissoring with the index-long fingers and those patients with very small thumbs.
When deepening the thumb-index web space, perform a release of the deep structures including the investing
fascia around the adductor pollicis. Ensure the princeps pollicis artery and its branches are identified and
protected.
When isolating the FDS distally, ensure the FDS is the FDS and not the FDP.
Release FDS-FDP connections and/or Camper's chiasm if the FDS does not easily roll into the forearm
incision.
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Ensure adequate space is present in the FCU loop to permit easy gliding of the FDS through the pulley.
Following the thumb incisions, assess for a pollex abductus and release it if present.
Circumduct the suture when pulling the FDS through the hole in the metacarpal head. If the tendon is too
large, remove one slip of the FDS.
Stabilize the ligament reconstruction with a Kirschner wire.
Place a long arm thumb spica cast to decrease the chance that the cast falls off.
The long arm thumb spica cast is maintained for 3 weeks. Upon removal of the cast, the Kirschner wire is
removed in the office and a short-arm thumb spica splint is fabricated. At this point in time, active motion and
therapy are initiated to work on tendon transfer firing and re-education. Protective splinting of the thumb is
continued until 3 months postoperatively.
COMPLICATIONS
The most common complication following reconstruction of a hypoplastic thumb is MCP joint stiffness.
However, the stability provided by ligament reconstruction is necessary to permit the formation of a stable
post for pinch and grasp. The mild stiffness that usually occurs has minimal impact on the functional
outcome that occurs following ligament reconstruction, assuming the IP and CMC joints are supple.
The most dreaded complication is vascular compromise, which can occur due to injury to the princeps
pollicis artery during the thumb-index web space release. Additional complications can include infection,
persistent MCP joint instability, weakness, and decreased motion. These complications can be minimized
by choosing appropriate patients for reconstruction and minimizing technical errors.
RESULTS
The results following reconstruction for thumb hypoplasia are generally good compared with preoperative
function as long as each deficient component of the thumb hypoplasia was addressed during the procedure
(18). However, the results are difficult to interpret and cannot be compared, as there is substantial
heterogeneity in the reconstructive techniques, severity of the hypoplasia, and patient populations.
REFERENCES
1. Soldado F, Zlotolow DA, Kozin SH: Thumb hypoplasia. J Hand Surg Am 38: 1435-1444, 2013.
2. Blauth W: The hypoplastic thumb [German]. Arch Orthop Unfallchir 62: 225-246, 1967.
3. Muller W: Die angeborenen fehlbildungen der menschlichen hand. Leipzig, Germany: Thieme, 1937.
4. Tupper JW: Polelx abductus due to congenital malposition of the flexor pollicis longus. J Bone Joint Surg
Am 51: 1285-1296, 1969.
5. Fitch RD, Urbaniak JR, Ruderman RJ: Conjoined flexor and extensor pollicis longus tendons in the
hypoplastic thumb. J Hand Surg Am 9: 417-419, 1984.
6. Lister G: Pollex abductus in hypoplasia and duplication of the thumb. J Hand Surg Am 16: 626-633, 1991.
7. Graham TJ, Louis DS: A comprehensive approach to surgical management of the type IIIA hypoplastic
thumb. J Hand Surg Am 23: 3-13, 1998.
8. Tay SC, Moran SL, Shin AY, et al.: The hypoplastic thumb. J Am Acad Orthop Surg 14: 354-366, 2006.
9. Kleinman WB: Management of thumb hypoplasia. Hand Clin 6: 617-641, 1990.
10. Nakamura J, Kubo E: Bilateral anomalous insertions of flexor pollicis longus. J Hand Surg Br 18: 312-
315, 1993.
11. Thomas C, Mathivanan T: Congenital absence of flexor pollicis longus without hypoplasia of the thenar
muscles. J Hand Surg Br 24: 385-386, 1999.
12. Aydinliolu A, Sakul BU, Diyarbakirli S: A rare insertion site for abductor pollicis longus and extensor
pollicis brevis muscles. Acta Anat (Basel) 163: 229-232, 1998.
13. Manske PR, McCarroll HR Jr, James MA: Type-IIIA hypoplastic thumb. J Hand Surg Am 20: 246-253,
1995.
14. Aliu O, Netcher DT, Staines KG, et al.: A 5-year interval evaluation of function after pollicization for
congenital thumb aplasia using multiple outcome measures. Plast Reconstr Surg 122: 198-205, 2008.
15. Kozin SH, Weiss AA, Webber JB, et al.: Functional results after index finger pollicization for congenital
aplasia or hypoplasia of the thumb. J Hand Surg Am 17A: 880-884, 1992.
16. Kozin SH: Pollicization: the concept, technical details, and outcome. Clin Orthop Surg 4: 18-35, 2012.
17. Foucher G, Medina J, Navarro R: Microsurgical reconstruction of the hypoplastic thumb, type IIIB. J
Reconstr Microsurg 17: 9-15, 2001.
18. Kozin SH, Ezaki M: Flexor digitorum superficialis opponensplasty with ulnar collateral ligament
reconstruction for thumb deficiency. Tech Hand Up Extrem Surg 14(1): 46-50, 2010.
Chapter 34
Index Pollicization for Congenital Absence and Hypoplasia of the
Thumb
Joseph Upton
INTRODUCTION
During the past five decades, no area of hand surgery has changed as much as thumb reconstruction.
Techniques for reconstruction following traumatic total or subtotal loss with the transposition of an index or other
digit were introduced and refined after the World War II era. Many ingenious methods of pollicization were
introduced as basic principles evolved. The introduction of microvascular techniques has made the reattachment
of amputated parts the procedure of choice following most traumatic injuries and, as such, has greatly reduced
the need for posttraumatic pollicization.
Despite our enthusiasm for microvascular applications in hand surgery and a plethora of new techniques, index
pollicization remains the procedure of choice for congenital absence and severe hypoplasia of the first ray. The
early contributions of Gosset, Hilgenfeld, and Bunnell in the treatment of traumatic loss were later refined for the
child with congenital differences by Littler and Buck-Gramcko. Over the past 25 years, we have built upon this
foundation and added further adaptations in a series of 270 pollicization procedures.
INDICATIONS
Thumb Hypoplasia and Absence Deformities
Any child with severe bilateral absence or hypoplasia of the thumb (types IIIB, IV, and V) is an excellent
candidate for pollicization, barring any accompanying major neurologic, cardiovascular, or hematologic
deficiency that would prevent the child from using the upper extremity effectively. Most experienced
surgeons would recommend this procedure for unilateral absence or hypoplasia as well. Those with severe
mental retardation or proximal limb deficiencies, such as shoulder-tohand phocomelia, may not be good
candidates. Important initial considerations in these patients include the motion status of the shoulder and
elbow, as well as the arm and forearm length, all of which determine the position of the hand and arm in
space. The child must be able to use her/his new thumb effectively to justify this procedure. Additional
indications include the rare mirror hand, five-fingered hand, and other unique malformations.
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FIGURE 34-1 A: Postoperative mold of two patients shows the difference between a thumb with a deep
web space on the left and one with a balanced and more natural web on the right. Both had normal index
fingers preoperatively. The hand on the right had more tissue advanced from the ulnar side of the thumb
into the web space. B: The hands of a 25-year-old accountant are seen 24 years following a pollicization of
the right hand and 21 years following the same procedure on the left side. Because she had a type III B
hypoplastic thumb on the left side, it took almost 3 years to convince the parents that this was the
appropriate procedure for the left hand.
Aesthetic Indications
The importance of appearance has been long overlooked by authors of congenital hand texts. Older
children, and particularly teenagers, prefer a one-thumb, three-fingered hand to the four-fingered hand with
or without the abducted and slightly pronated index finger. When the normal or slightly stiff index finger has
been repositioned as a thumb early in life, all children will adapt and use this ray effectively as a thumb.
Creation of a deep, broad first web space, and the size of the intrinsic muscles on the radial side of the
thumb, are key variables that impact the final appearance of the new thumb, which, distally, will always be
thinner than the normal thumb.
Type IIIB Thumb
The decision to ablate a good-looking thumb with large phalangeal components and a deficient metacarpal
(MP) with no carpometacarpal (CMC) joint is difficult for parents in most cultures. In our experience, these
families are usually members of strict religious groups and believe that God put it there for a reason.
However, many of these patients have bilateral, asymmetrical malformations. It is best to pollicize the most
normal index digit first so that the parents may become encouraged by the early outcome and agree to have
the same procedure on the opposite hand (Fig. 34-1). However, it is not always possible to convince some
parents, who will doctor shop until they find a surgeon willing to build upon the existing hypoplastic thumb.
Stabilization of the deficient thumb MP with bone or tendon grafts followed by tendon transfers can be
completed in multiple stages. Microvascular transfer of the second toe MP joint with overlying soft tissue to
reconstruct the new thumb CMC joint has also been performed in these thumbs. The long-term outcomes
have been less satisfactory than a well-performed index pollicization. All experienced pediatric hand
surgeons prefer the index pollicization to microvascular alternatives for these indications.
CONTRAINDICATIONS
Children with severe associated malformations, especially neurologic, with little chance of function should not be
subjected to this additional operation. However, these bedridden patients should be distinguished from those
ambulatory children with mild retardation who use their arms and hands
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adroitly in their activities of daily living. All cases must be individualized, as there are very few absolute
contraindications for this procedure.
Those with radial deficiencies have a smaller, stiff, often-contracted index ray and are not good candidates for a
formal index pollicization. Judicious rotation-recession osteotomy of the index ray with and without joint
arthrodeses is often preferred.
In some cases of thumb hypoplasia, the remaining elements are severed enough to initiate augmentation instead
of pollicization. Despite the intellectual appeal of maintaining a five-digit hand, reconstruction of some of their
type IIIA thumbs is demanding, and results are often inferior to pollicization.
Physical Examination
A careful physical examination is often all that is necessary to adequately assess these hands. These patients
usually fall into two major groups: those with a normal index finger and good thenar muscles and those with
radial dysplasias, previous centralizations, and stiff index rays. A detailed documentation of active and passive
range of motion, the presence and strength of intrinsic muscles, and flexion contractures of the index and/or
other digits should be carefully recorded. Videotapes provided by occupational therapists are very helpful for
evaluations of older children and all postoperative patients.
Radiology
Routine anteroposterior (AP) and lateral radiographs are obtained. Angiograms are obtained only on limbs with
unusual anomalies, such as the mirror hand or other bizarre malformations in which the arterial blood supply to
the index digit may be in question.
Parents and Family

Often, the surgeon's hardest job is to counsel discriminating parents who have carefully watched their child
adapt to every task presented. The use of pre- and postoperative hand molds, photographs of other patients,
and actually meeting other patients who use their new thumbs are quite useful. It is very important to give the
parents of these children an accurate expectation of the postoperative outcome and to emphasize the diminished
pinch and grasping ability of these new thumbs. These new thumbs will never be normal, but the final outcome
will be better than those achieved with alternative reconstructions.
Timing of Pollicization
Some controversy will always exist regarding the optimal time for an index pollicization. Although some
experienced surgeons such as Dieter Buck-Gamcko and Guy Fouchet have performed these operations on
children less than 4 months of age, most wait until the child is between 12 and 24 months of age. Pollicization in
a 12-month-old toddler is much easier than that in a 2- to 3-month-old baby. I have found that the size of the
hand and not the chronologic age of the child is the primary consideration. Other advantages of waiting include
improved cooperation of the child and increased likelihood of performing a much more precise operation on a
larger hand. The 1- to 2-year age range is also preferable with our limited knowledge of neuromuscular
maturation and central conditioning and plasticity of the cerebral cortex.
SURGERY
Incisions
In contrast to posttraumatic thumb reconstructions, adequate skin cover is present in congenital cases, and the
need for skin grafts is usually a reflection of poor incision planning. A racquetshaped incision is made across the
base of the thumb 1.0 to 2.0 mm proximal to the digitopalmar flexion crease. The radial extension of this incision
may extend either toward the palm or directly along the radial border of the hand (Figs. 34-2 and 34-3). Once this
incision is made through the dermal layer, upward traction of the skin will enhance the decompression of the
fibrous septae, anchoring the skin to the palmar aponeurosis. If this dissection is kept above the palmar fascia,
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there is no danger of neurovascular injury. The palmar aponeurosis should not be elevated with the flap (Fig. 34-
4, bottom).
FIGURE 34-2 Top: Preoperative appearance and radiograph of hand with a congenital absence of the thumb
(type V). Abduction and autopronation of the most radial ray are common. Joint motion is normal. Bottom: The
palmar incision marks the presence of the future thenar flexion crease, is made 2.0 to 3.0 mm proximal to the
digitopalmar flexion crease, and extends toward the base of the index finger. The markings on the dorsal view
indicate the most likely position of dorsal veins (arrows). The circle on the palmar surface indicates the planned
change of position.
FIGURE 34-3 Alternative incisions have been used in the presence of hypoplastic thumbs. The most important
and permanent landmark is the position of the new thenar flexion crease. Additional skin is not needed for index
pollicization. One should save as much tissue as possible and discard extra flap after the thumb has been seated
in full palmar abduction.
The dorsal incision extends over the index finger at the MP joint level. In most children, two large dorsal veins
can be located on either side of the dorsal midline. Once the tight dermal layer has been penetrated, upward
traction of the skin flap will enable both sharp and blunt scissor dissections between the two layers of fat on the
dorsal surface of the hand. The important dorsal veins and nerves are located between these two layers, which
may not be anatomically distinct but which are easily separated with proper retraction (Fig. 34-4, top). If the
surgeon retains a generous layer of fat on the dorsal flap, the blood supply to this region will not be
compromised. The dorsal flap is raised three to four centimeters proximal for visualization of the venous drainage
plexus and to allow ligation of branch(s) to the long finger, which, if left intact, will tether full proximal movement
of the digits later in the procedure (Fig. 34-4).
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FIGURE 34-4 Top: The dorsal incision is made to the subdermal plane. Upward traction and scissor dissection
separate the two layers of fat. The dorsal veins and nerves are in the deep layer. A connecting branch to the
long finger (beneath green background) is ligated. Bottom: The palmar flap is raised above the palmar
aponeurosis and extended ulnar only far enough to expose the neurovascular bundle. Note the asymptomatic
neuroma that formed after removal of a hypoplastic thumb (type IV) in the newborn nursery. Both bundles are
exposed, with a red loop around the radial digital artery to the long finger.
One of the most important functions of these incisions is the creation of a normal-appearing first web space,
which means extending the level of the web on the ulnar side of the new thumb to the MP joint, formerly the
index proximal interphalangeal (PIP) joint. This is accomplished by advancing tissue from the ulnar side of the
new thumb into the new web space. The dorsal cutback incision, which permits this advancement and is delayed
until the precise location of the incision, can be made later in the operation.
Incisions: Types IIB and IV

Small nonfunctional thumbs attached by diminutive soft-tissue pedicles should be ablated in the newborn
nursery. The larger, hypoplastic thumb is usually saved until a later decision can be made in regard to its
usefulness. There is no standard method for the introduction of this tissue. It is best to plan incisions first as
though there were no thumb remnant, and then, one can incorporate the extra tissue into the original design
(Figs. 34-3 and 34-4).
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In addition to the types IIB and IIV thumb hypoplasias, a small thumb may be joined to the index ray by a simple
or complete soft-tissue syndactyly, most commonly seen in the Holt-Oram syndrome (congenital heart defect plus
a radial dysplasia). Occasionally, a mitten hand will present with thumb absence and syndactyly between the
index and long digits. There is no consensus upon whether to treat these soft-tissue connections prior to or at
the same time as index pollicization. Twenty years ago, we performed these separately but now prefer to correct
everything at the time of pollicization.
Soft-Tissue Dissection
Neurovascular Structures Following elevation, the dorsal and palmar flaps are secured with traction sutures.
The palmar flap does not need to be elevated further than the longitudinal fibers of the palmar aponeurosis to the
long finger. Removal of these fibers to the index finger exposes the palmar arch and common vessels to the
index long web space. The distal bifurcation is identified and the ulnar arborization looped. Neural loops around
either side of the vessels (artery and venae comitantes) are easily identified with traction on the common nerve
(Fig. 34-5, top). Neural loops can be gently teased apart. The rarely encountered arterial loop around the nerve
requires ligation of one limb without disturbance of the vascular continuity. The distal bifurcation to the radial side
of the long finger is then ligated.
In contrast, the entire vascular bundle to the radial side of the index digit does not require much manipulation.
These vessels are much smaller than the dominant vessels on the ulnar side of the index finger.
FIGURE 34-5 Top: The radial neurovascular bundle has been isolated. On the ulnar side, careful scrutiny for
the presence of arterial or neural loops must be done. Bottom: The first annular pulley is dissected in the
midline and decompressed. Following ligation of the artery to the long finger, the transverse MP ligament is
easily identified before transection.
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Connective Tissue Following identification of both neurovascular bundles, the A-1 pulley is identified with
midline scissor dissection. A full trigger release extending up into the A-2 pulley is performed. The transverse MP
ligament (intervolar plate ligament) within the index long web space is exposed and transected (Fig. 34-5,
bottom). This affords an increased mobility of the index ray. Investing fascia of the palmar interosseous muscle,
the dorsal interosseous muscle, and the dorsal fascia within the subcutaneous tissue planes are next released.
Intrinsic Muscles The insertion of the intrinsic muscles to the index finger is then detached and the individual
muscles raised and mobilized. The insertions of the first dorsal interosseous are best identified with incision of
the fascia over the lumbrical to the index finger (Fig. 34-6, top
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right) and following the muscle to its attachment to the extensor mechanism, where the insertions of the first
dorsal interosseous muscle (abductor indicis muscle) are easily visualized (Fig. 34-7). At least 2.0 to 3.0 mm of
distal aponeurosis is retained for suture fixation when these bone and tendon insertions are detached. The first
dorsal interosseous muscle varies in size and bulk tremendously and with normal index rays often has two parts,
an outer muscle to the extensor mechanism and a large inner muscle belly inserting into the base of the proximal
phalanx. The distal one-half of these intrinsic muscles are teased apart and their proximal periosteal and other
soft-tissue origins not dissected.
FIGURE 34-6 Top: Additional mobility of the index ray is obtained with release of fascial bands between intrinsic
muscles. The distal aponeurosis and distal insertion of the radial intrinsic muscles are easily located with release
of the investing fascia from proximal to distal. Bottom: At least 2.0 to 3.0 mm of aponeurosis should be kept for
securing sutures. The first DI often has more than one muscle belly.
FIGURE 34-7 Rebalancing of the extrinsic and intrinsic muscles from a left index finger to the new left thumb
(right). DP, distal phalanx; MP, middle phalanx; PP, proximal phalanx; M, metacarpal; DIPJ, distal interphalangeal
joint; PIPJ, proximal interphalangeal joint; MP, metacarpophalangeal joint; CMCJ, carpometacarpal joint; EDC,
extensor digitorum communis tendon; EIP, extensor indicis proprius tendon; 1st PI, first palmar interosseous
(ulnar interosseous) muscle; 1st DI, first dorsal interosseous muscle (radial interosseous, abductor indicis);
AbPB, abductor pollicis brevis; AddP, adductor pollicis muscle; FPB, flexor pollicis brevis muscle; AbPL, abductor
pollicis longus tendon.
Skeletal Shortening Once the soft-tissue dissection has been completed, the index MP is exposed, the extensor
tendon and dorsal veins are retracted, and subperiosteal dissection is completed from the MP base to the
epiphyseal plate within the MP head. The collateral ligaments and palmar plate stabilizers to the MP joint are
preserved. The periosteum and fascia of the palmar (ulnar) interosseous muscle are usually the final fibers to be
released during this part of the dissection. Two MP osteotomies are done: a distal cut through the epiphysis (Fig.
34-8, top right) and an oblique proximal cut through the metaphysis.
The MP head is then recessed (shortened) and rotated in 90 to 100 degrees of pronation and fixed with one or
more nonabsorbable sutures anterior to the index MP base with the index MP joint (now the thumb CMC joint) in
a hyperextended position (Fig. 34-9). This joint positioning, as advocated by Buck-Gramcko, prevents
hyperextension of the new thumb. Note that the index MP joint is a hyperextension joint and the normal thumb
CMC joint is not a hyperextension joint. This repositioned new thumb lies (1) with the MP head pronated 100
degrees (relative to its former position), (2) flexed 35 to 40 degrees, and (3) abducted 20 to 30 degrees in a
radial position.
This skeletal shortening and recession is one of the most critical steps in a pollicization procedure and usually
occurs at the end of a normal tourniquet run of 90 minutes. Placement of the MP head is often facilitated by the
dissection of a space anterior to the base of the index MP during the periosteal elevation.
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FIGURE 34-8 Top: Periosteum is elevated over the entire MP and the intrinsic muscles left attached to the
periosteum. The illustration shows the placement and extent of MP resection. Bottom: This distal osteotomy is
through the epiphysis, which appears white and is easily distinguished from cancellous bone. An interosseous
suture is used to fix the hyperextended MP head anterior to the base of the index MP. The schematic illustration
shows the repositioning of the MP head, which becomes the thumb trapezium.
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FIGURE 34-9 Top: A normal index metacarpophalangeal joint is a hyperextension joint. In some individuals, up
to 90 degrees of hyperextension beyond neutral position is possible. Middle: The placement of the MP head,
which becomes the new thumb trapezium, anterior to the base of the MP creates a new transverse palmar arch
and more effectively places the thumb in a more palmar position. Bottom: An oblique cut is made in the MP
base just above the CMC articulation.
Incision The rotation-recession maneuver of the index finger invites a Y-to-V advancement of tissue from the
radial side of the hand into the dorsal and/or radial surface of the new thumb. The exact placement of the
incision is determined by the tissue availability. The thumb is first held in a position of full palmar abduction and
the soft tissue draped over it. A longitudinal incision, usually dorsal but sometimes more radial, extends out to the
new MP extension crease (Fig. 34-10).
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If performed before tourniquet release, the dorsal venous system is easier to identify and to dissect. This incision
then provides excellent exposure of the entire extensor mechanism and releases tissue for advancement from
the ulnar side of the thumb toward the radial side of the long finger. This movement provides a much more
pleasing and normal-appearing first web space.
FIGURE 34-10 With the new thumb held in optimal palmar abduction, the available skin flap is then draped over
the thumb. At this point, the exact placement of the cutback incision can be determined. The soft tissue on the
ulnar side is advanced into the new first web space, and that on the radial side is used to improve the bulk of the
thenar region.
Extrinsic Tendon Rebalancing The extrinsic flexor tendons are not altered, as they will shorten and adjust to
proper tension with time and growth. Within 18 months, strong flexion is present. This is not true for the extensor
muscle tendon units, which must be shortened (Fig. 34-11). Alteration of the flexor is helpful and indicated in the
stiff index finger, where there are predictable changes in the flexor mechanism.
Distally, the lateral bands are separated from the central portion of the extensor, and proximally, the indicis
proprius is separated from the more radial central extensor tendon. Both are incised. The common extensor is
advanced to the base of the thumb MP held in 40 degrees of extension. Insertion well to the ulnar side provides
an additional amount of pronation to the thumb ray. The extensor indicis proprius is then shortened and
reattached to the central portion of the extensor mechanism to become the extensor pollicis longus. End-to-end,
simple overlap, or interweave suture techniques work equally well.
FIGURE 34-11 The lateral bands are separated from the central portion of the extensor mechanism. The index
EDC is attached to the ulnar base of the new thumb MP, and the EIP is shortened and attached to the central
extensor of the index to become the new thumb EPL.
Intrinsic Muscle Reattachment The intrinsic muscles are next reattached (Fig. 34-11). The first PI becomes the
adductor pollicis and is attached to the ulnar side of the thumb proximal phalanx (formerly the index middle
phalanx). Some surgeons prefer to interweave the lateral band through this muscle, which then makes it part of
the extensor mechanism. This muscle is often small and has poor mechanical advantage as an adductor of the
thumb. However, strength can be reinforced by transfer of a superficial flexor tendon at a later date.
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The first DI (radial interosseous, abductor indicis) is attached to the radial side of the proximal phalanx (formerly
the index middle phalanx). If two muscles are present, which is often the case, the more external part is
interwoven into the extensor mechanism and the inner portion attached directly to the proximal phalanx to
simulate the abductor pollicis brevis, thereby providing strong abduction and a strong resistance to
hyperextension.
Skin Closure Skin closure provides a remarkable amount of stability to the ultimate position of the new thumb in
palmar abduction. The most proximal portion of the radial flap is first inset into the base of the new thenar
eminence, which is then established and closed with absorbable 5-0 and 6-0 mild chromic sutures. The upper
portion of the first web space at the base of the long finger is closed next. If the thenar flexion crease is in an
optimal position, the tissue on the ulnar side of the thumb has been advanced into the new first web space. The
flap from the dorsum of the hand is next advanced over the thumb and first web space. Necessary trimming is
often needed to create a gentle web, which extends between the thumb and long finger at the MP joint level. If
this web is excessively deep, the new thumb will retain its appearance as a digit (Fig. 34-12). The excessive fat
that is often present in young children may be found on the dorsal surfaces. This should be gently dispersed
beneath the skin flap and debulked at a later date.
FIGURE 34-12 Top: The new first web space extends gently between the MP joint of the thumb and index
fingers. If the index ray were transposed without soft-tissue alteration, an unusually deep web space would
result, and the transposed ray would appear more like a digit than a thumb. With advancement of the dorsal
tissue from the index and advancement of the local tissues, a normal web can be achieved. Bottom: With proper
positioning, the simulation of the normal web space as seen 4 months postoperatively is critical to the
appearance of the new thumb.
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Technical Caveat: Position of the Stiff Index Finger Motion limitations at the interphalangeal joint levels of the
index are not a contraindication to formal pollicization. Many children present with a normal, mobile index on one
side and a stiff, contralateral index associated with a radial deficiency. It is wise to transpose the normal index
first. On the opposite hand, as much active and passive motion should be gained before pollicization. This often
may involve a joint release with Z-plasty, a formal syndactyly separation, or an excision of a hypoplastic thumb.
Once the MP head is fixed anterior to the index MP base, the new thumb should be placed in full palmar
abduction with limited flexion. Because the thumb will function more as a mobile post than a thumb with full active
range of motion, it should be positioned closer to the long finger and with enough pronation to make thumb-to-
long-finger contact possible (Figs. 34-1 and 34-13). The extrinsic flexor is also shortened appropriately because
the increases of muscle excursion and strength with growth are not as predictable when the entire muscle
tendon unit is hypoplastic (Fig. 34-14).
FIGURE 34-13 This child had a normal index finger on the left hand and a stiff index association with a radial
club hand on the right hand. During the formal pollicization, the left side was placed in greater palmar abduction
and extension with a larger first web space than the right side, where limited mobility of the thumb is predictable.
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FIGURE 34-14 Top: This patient with the Holt-Oram syndrome has a hypoplastic thumb syndactylized to the
index ray with a complete syndactyly. In one operation, the hypoplastic thumb was removed prior to a formal
index pollicization. Because this digit is stiff, it is positioned closer to the long finger in less palmar abduction.
Bottom: Eighteen months later, he has maintained an excellent pinch and grasp between the less-than-normal
thumb and the best ray of the hand, the fifth digit.
The incisions are covered with Xeroform, one layer of wet gauze, and an additional layer of dry gauze. A bulky
fluff dressing is then applied, and the entire upper extremity is immobilized with a well-padded long arm cast
extending well proximal to the elbow flexed 90 degrees. This flexed position must be maintained during the
application of the soft dressing, in order to avoid antecubital pressure, which can potentially occur when the
extremity is wrapped in extension and then flexed at the elbow. The distal half of the thumb is exposed, and the
parents are instructed to call if the thumb begins to disappear into the dressing, a sure sign that the child is
beginning to wiggle out of the cast.
Three to four weeks later, this cast is removed under sedation and a thumb spica splint made for wear at night.
An active range-of-motion program is started, and no restraints are placed on the child during preschool or at
play.
RESULTS
The new thumb will never be normal because the skeletal foundation, including an intact CMC joint
stabilized by a normal cone thenar muscle, is absent. Nail width, pulp volume, phalangeal lengths, joint
relationships, and thenar and web space contours will not precisely mimic the normal thumb (Fig. 34-15).
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FIGURE 34-15 Top: Four years after pollicization of an index finger with normal range of motion and
complement of intrinsic muscles, good flexion and full extension of the thumb is demonstrated. The thumb to
long finger pinch is approximately 60% of normal for his age and sex. Palmar abduction through the AbPB
(formerly the first DI) is present but weak. Bottom: Despite the slender distal contour, the gentle curve of
the first web space makes this digit appear more like a thumb than a transposed index finger.
A review of the literature over the past 50 years shows that although more parameters for measurement
have been developed, the basic conclusions have not changed: Those with a normal index ray prior to
pollicization had much better outcomes than those with associated conditions such as the radial club hand,
a mirror hand, a five-fingered hand, or following a previous syndactyly release. An ongoing study of our
outcomes greater than 10 years postoperatively definitely reveals these two general groups of patients.
Any assessment of the aesthetic and functional outcomes following pollicization is difficult at best. Manske's
careful follow-up of 52 patients included range of motion, strength (pinch and grip), hand usage, and a
timed-activity test. This study of two case reports confirmed the observation that following pollicization of a
normal index finger, there was a marked reduction in strength in comparison to a normal thumb. However,
these new thumbs did function significantly better than a pollicized index finger associated with radial club
hand, mirror hand, five-fingered hand, or a syndactyly. However, the diminished function does not mean
that these children do not use their hands. To the contrary, they adapt quite effectively, and their primary
deficit is the manipulation of small objects. Secondary procedures such as opposition transfers and
arthrodeses were more commonly performed in the latter group.
The appearance of a pollicized digit is much more difficult to determine because of the subjective
interpretation required. Some have tried to quantify by measuring the length of the digit relative to the PIP
flexion crease, the resting posture of the new thumb, and the rotation relative to the other digits.
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Others have emphasized the creation of a web across the first web space, which avoids the appearance of
a finger positioned on the side of the hand. We have observed that the parents and grandparents are
almost uniformly pleased with the postoperative appearance and that the patients do not have much of an
opinion until they are teenagers, at which time many will let you know whether they like their thumbs or not.
Just ask!
COMPLICATIONS
Most problems occur as a result of inexperience and/or a hastily performed operation. Although we have
never seen vascular compromise following index to thumb transposition, this catastrophe can occur.
Infection and hematomas are rare, but wound dehiscence and maceration, often interpreted as infection,
may result from inadequate immobilization, the primary cause of complication in pediatric hand surgery.
Failure to ablate the growth plate with the MP osteotomy will enable the new thumb to grow at the MP level
and become too long. Hyperextension of the new thumb will occur when the index MP head, which
becomes the thumb trapezium, is not seated in hyperextension. Islands of bone spicules will develop within
periosteum left attached to intrinsic muscles, but this rarely affects function. Adherence of the extrinsic
tendons will occur more commonly on the extensor side than the flexor side. However, these potential
problems have occurred in less than 10% of our cases.
Deficient strength in both pinch and grasping should not be interpreted as complications. Similarly, poor
abduction power or adduction strength necessitating secondary tendon transfers is more a function of the
malformation than complication related to poor judgment or technical errors on the part of the surgeon.
Undeniably, experience is essential with the index pollicization procedure, which is perhaps the most
elegant in hand surgery. Both improvement of outcomes and refinement of one's technique can only be
gained with a very critical appraisal of individual results!
RECOMMENDED READING
1. Barton N, Buck-Gramcko D, Evans DM, et al.: Mirror hand treated by true pollicization. J Hand Surg Br
11B: 320-336, 1986.
2. Bayne LG: Long-term review of the surgical treatment of radial deficiencies. J Hand Surg Br 12A: 169-179,
1987.
3. Buck-Gramcko D: Pollicization of the index finger: methods and results in aplasia and hypoplasia of the
thumb. J Bone Joint Surg 53A: 1605-1617, 1971.
4. Buck-Gramcko D: Pollicization in congenital malformations of the hand and forearm. In: Buck-Gramcko D,
ed. Congenital malformations of the hand and forearm. London, UK: Churchill-Livingstone, 1988: 379-402.
5. Buck-Gramcko D: Complications and bad results in pollicization of the index finger (in congenital cases).
Ann Chir Main Memb Super 10: 506-512, 1991.
6. Dijkstra-Zwollw R: Functional results of thumb reconstruction. Hand 14: 120-128, 1982.
7. Eaton C, Lister GD: Syndactyly. Hand Clin 6: 555-575, 1990.

8. Egloff D, Verdan CL: Pollicization of the index finger for reconstruction of the congenitally hypoplastic or
absent thumb. J Hand Surg Br 8: 839-848, 1990.
9. Erhardt R: Sequential levels in the development of prehension. Am J Occup Ther 28(10): 592-596, 1974.
10. Flatt A: The absent thumb in congenital hand anomalies. St. Louis, MO: Quality Medical Publishing,
1994.
11. Harrison S: Pollicisation in cases of radial club hand. Br J Plast Surg 3: 192-200, 1970.
12. Harrison H: Upper limb anomalies: pollicization for congenital deformities of the hand. Proc R Soc Med
66: 634-638, 1973.
13. Hentz VR: The surgical management of congenital hand anomalies. In: Littler J, ed. Reconstructive
plastic surgery. 6. The hand and upper extremity. Philadelphia, PA: WB Saunders, 1977: 3306-3349.
14. Hentz VR: Traditional techniques for thumb reconstruction: guidelines for indications. In: Landi A, ed.
Reconstruction of the thumb. London, UK: Chapman Hall Ltd., 1990: 170-186.
15. Kaplan EB: Functional and surgical anatomy of the hand. Philadelphia, PA: Lippincott Williams & Wilkins,
1984.
16. Lister G: The choice of procedure following thumb amputations. Clin Orthop 195: 45-51, 1985.
17. Littler J: Neurovascular pedicle method of transposition for reconstruction of the hand. Plast Reconstr
Surg 12: 303-319, 1953.
18. Manske P: Reconstruction of the congenitally deficient thumb. Hand Clin 8: 177-196, 1992.
19. Manske P, Rotman MB, Dailey LA: Long-term functional results after pollicization for the congenitally
deficient thumb. J Hand Surg Br 17A: 1064-1073, 1992.
20. Michon J, Merle J, Bouchon Y, et al.: Functional comparison between pollicization and toe-to-hand
transfer for thumb reconstruction. J Reconstr Microsurg 1: 103-112, 1984.
21. Percival NJ, Chandraprakasam T: A method of assessment of pollicisation. J Hand Surg Br 16B: 141-
143, 1991.
22. Roper B, Turnbull TJ: Functional assessment after pollicisation. J Hand Surg Br 11B: 399-403, 1986.
23. Sekiguchi J, Ohmori K, Kobayashi S, et al.: Functional results after pollicization in congenital cases. J
Jpn Soc Surg Hand 10: 890-894, 1994.
24. Sherik SK, Flatt AE: Functional evaluation of congenital hand anomalies. Am J Occup Ther 25: 98-104,
1971.
25. Sykes PJ, Percival NJ: Pollicization of the index finger in congenital anomalies. J Hand Surg Br 16B: 144-
147, 1991.
26. Taylor N, Jebsen RH: Evaluation of hand function in children. Arch Phys Med Rehabil 54: 129-135,
1973.
27. Upton J: Pollicization for the aplastic thumb. In: Marsh J, ed. Current therapy in plastic and reconstructive
surgery: trunk and extremities. Toronto, ON: BC Decker, 1989: 232-237.
28. Ward J, Pensler JM, Parry SW: Pollicization for thumb reconstruction in severe pediatric hand burns.
Chapter 35
Great Toe Transfer Thumb Reconstruction
Jonathan Amer Zelken
James P. Higgins
INTRODUCTION
Absence of the thumb can be broadly classified into congenital and acquired deformities. The spectrum of
congenital thumb hypoplasia is conventionally addressed with augmentation (i.e., web space deepening) in less
severe forms or pollicization of the index finger in more profound deficiencies (i.e., Blauth stage IV or V
hypoplasia). Free toe transfer reconstruction is not preferred in this setting because of the absence of radial-
sided anatomic support structures that would be required to yield optimal results (i.e., carpometacarpal [CMC]
joint, thenar musculature, extrinsic tendons, radial artery, etc.).
Free toe transfer reconstruction is most commonly employed in acquired absence of the thumb, whether
traumatic (amputations, failed replantation) or extirpative (amputation performed for infection, neoplasm). Either
the first or the second toe may be transferred for digit reconstruction. Due to its small size and breadth, the
second toe is generally used to reconstruct digits 2 to 5, or in pediatric posttraumatic thumb reconstruction. The
great toe provides a stronger and better cosmetic result (1,2). A systematic review suggests there may be
improved survival, total active motion, grip strength, and key pinch strength in great and trimmed great versus
second toe transfer. Furthermore, patients were more satisfied with the recipient site function and aesthetics
after trimmed great toe transfer (3). Both techniques confer similar sensory outcomes (4,5).
This installment will describe the technique of great toe transfer for acquired absence of the thumb.

The ideal setting for great toe reconstruction is posttraumatic or postsurgical absence of the thumb at, or distal
to, the level of the metacarpal neck, with a supple and stable CMC joint, functioning thenar musculature,
available digital nerves for reinnervation, and a generous soft-tissue envelope. These criteria are not required for
successful great toe reconstruction but provide the best opportunity for functional success.
Bone Length
The morbidity of harvest of the great toe is minimized by harvest distal to the metatarsophalangeal (MTP) joint.
This allows for flexion of the MTP joint via the flexor hallucis brevis and aids propulsion. It also preserves the
windlass mechanism, wherein the plantar fascia inserts into the base of the proximal phalanx and flexes the first
metatarsal, allowing it to bear the majority of body weight during the stance phase of gait (6). Finally, harvest at
this level maintains joint capsular integrity, the position of the volar plate, and sesamoids. The length of the great
toe is sufficient to reconstruct thumb defects at the metacarpal neck or through the metacarpophalangeal (MCP)
joint by
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performing an MCP/MTP arthrodesis. If the thumb amputation is through the shaft of the proximal phalanx,
osteosynthesis can be performed at the diaphysis of the respective proximal phalanges. If the thumb amputation
is through the interphalangeal joint (IPJ), the toe transfer can be prepared by removal of the proximal phalanx
and stabilized by arthrodesis through the IPJ.
Thumb amputations at, or proximal to, the metacarpal shaft pose a particular challenge. The surgeon may elect
to perform the great toe transfer with intercalary corticocancellous bone graft (i.e., iliac crest) to restore length
not provided by the great toe (7). Alternatively, a second toe transfer may be performed with adequate length of
metatarsal to achieve direct metatarsal/metacarpal osteosynthesis.
CMC Joint and Thenar Musculature

Great toe transfer reconstruction does not routinely provide significant MCPJ or IPJ range of motion (3,8).
Trimmed great toe transfer has shown to result in even less IPJ motion, presumably since the capsule is invaded
and the joint osteotomized by design (9). Its success is predicated on a stable and mobile CMC joint providing
multiplanar motion. The ideal setting for successful reconstruction is one where the CMCJ is uninjured, supple,
and powered by healthy innervated thenar musculature. If the trauma has fractured or ankylosed the CMCJ,
amputated the entire metacarpal, or destroyed all of the thenar musculature, the reconstruction will be minimally
functional. The surgeon and patient have to weigh the benefit of toe transfer reconstruction anticipating the
thumb serving only as an immobile digit, with all prehension dependent on the mobility of the nonthumb digits.
The surgeon should not consider the repair/reconstruction of the extensor and flexor pollicis longus (EPL and
FPL) as a reasonable substitute for thenar musculature, as they will not provide coordinated CMC motion.
Sensory Nerves
In routine toe transfer thumb reconstruction, the toe digital nerves are coapted to the amputated stumps of the
thumb digital nerves in the field of dissection just proximal to the traumatic scar. This provides tension-free
atraumatic nerve coaptations near the sensory targets. In traumatic thumb avulsion injuries, however, the digital
nerves may be avulsed from the median nerve in the carpal tunnel. In this setting, the surgeon and patient should
plan on digital nerve sensory transfers from nearby noncritical dermatomes (typically the common and proper
digital nerves to the third web space) and anticipate the donor site deficit inherent to the nerve transfer.
Regardless of the multitude of technical aspects of toe transfer reconstruction, the surgeon should always mind
the critical importance of sensory return in the ultimate use or neglect of the transferred toe by the patient
(10,11).
In the rare setting of trauma involving thumb amputations and concomitant forearm level median and/or ulnar
nerve injuries, the ability to restore sensation must be critically assessed. A complete median nerve sensory loss,
for example, may be a contraindication to thumb reconstruction unless nearby donor nerves (i.e., digital nerves to
the fourth web space) are available and deemed expendable for transposition to the toe transfer.
Skin Envelope
This is the least stringent of the listed requirements for toe transfer reconstruction of the thumb, but still deserves
considerable preoperative attention. The great toe donor site provides very limited skin from the dorsal and
plantar surfaces. If the thumb amputation site has firmly adherent scar tissue and there is no supple or excess
soft tissue, the skin envelope will likely be inadequate for skin closure upon completion of the toe transfer
procedure. Skin grafts may be employed if the wound bed permits (Fig. 35-1). Alternatively, staged
reconstruction may be considered. The first stage involves
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providing excess soft-tissue coverage of the amputation stump. This is commonly performed using a pedicle
groin flap or free fasciocutaneous flaps (i.e., lateral arm, anterolateral thigh flaps). When the skin has healed and
edema resolved (usually 2 or 3 months after skin flap procedure), the toe transfer can be performed with greater
assurance that skin closure can be obtained over hardware, tendons, nerves, and vessels.
FIGURE 35-1 The inset trimmed great table and its satisfactory perioperative appearance. Skin graft is often
used to augment soft-tissue coverage. Note the extended posture of the thumb, pronation, length, and girth.
General
The great toe flap results in perhaps the most visibly deforming appearance after harvest than any other free flap
(Fig. 35-2). It also provides the opportunity for the most dramatic elevation in overall function than any other free
flap (3). A well-informed and carefully deliberated decision requires significant effort by both the patient and
surgeon. It is for this reason that “acute toe transfer” surgeries are rarely performed. Some authors, however,
have shown that early reconstruction may be associated with reduced convalescent time and better sensory
recovery (12,13).
The experienced toe transfer surgeon should have available a portfolio of images of preoperative and
postoperative results of similar cases for the prospective patient to examine. We have also found many previous
toe transfer recipients to be willing resources for prospective toe transfer patients to contact and discuss
function, donor site issues, and the reconstructive/recovery experience. It is also helpful to have patients
evaluated by a prosthetist so they may have a complete understanding of all options available to them.
FIGURE 35-2 Cosmetic and donor site morbidity are significant after toe transfer. A wellinformed decision
requires significant effort by both patient and surgeon.
Recipient Site
Closure of the amputation stump is achieved with preservation of as much soft tissue as possible (even if it
appears grossly excessive) in anticipation of possible toe transfer reconstruction. If there is insufficient soft tissue
at the recipient site, it should be supplemented. The pedicled groin flap is a reliable and rapid means of
augmenting the amputation site without requiring dissection of sites for future microanastomoses (i.e., the radial
artery in the snuffbox) (Fig. 35-3). The groin flap donor site provides generous amounts of supple skin, and the
donor site scar is easy to conceal. Alternatively, free fasciocutaneous or fascia flap transfer can be considered.
In this setting, we make an effort to perform the anastomosis to the radial artery at the distal volar forearm in an
end-to-side fashion. The subsequent toe transfer can then be perfused by anastomosis “downstream” in an end-
to-side anastomosis in the radial artery in the snuffbox.
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FIGURE 35-3 A: When soft-tissue coverage at the base of the thumb is in question, such as after a failed
replantation effort, staged soft-tissue augmentation is advised. B: Markings for pedicled groin flap. C: The tubed
flap is divided 3 weeks after elevation. D,E: After flap healing, toe transfer may be performed.
Donor Site
The donor foot should demonstrate palpable pulses to safely proceed with toe transfer surgery. Lack of palpable
pulses suggests a significant risk of flap loss or foot ischemia after harvest. Preoperative angiography is not
routinely performed at this institution. While the “dominant” blood vessel to the great toe may be plantar or dorsal
in the first web space, this may be determined intraoperatively and would not alter preoperative planning to
warrant routine angiographic assessment of patients with palpable pedal pulses.
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The donor side is selected by comparing the appearance of the right and left great toe and the uninjured thumb.
Either toe is selected if the size or morphology of the toe or nail complex is thought to be superior for creation of
the new thumb compared to the opposite toe. If they are equivalent, we prefer to harvest the left great toe solely
because of the need for the great toe in activating the accelerator while driving an automobile. Alternatively, if the
patient has a strong side preference, this should be taken into consideration.
Whether the donor vessel drapes radially or ulnarly from the reconstructed thumb does not pose a significant
challenge in insetting the toe and should not influence harvest side selection.
TECHNIQUE
This procedure is most efficiently achieved with a two-team approach, so that great toe harvest can be
approaching completion by the time the hand preparation is complete. The supine patient should be positioned
such that the heel of the donor foot is at the edge of the operative table. This facilitates dissection of the plantar
surface of the foot. Tourniquets are used on both the upper and lower extremities.
Preparation of the hand
1. A sweeping incision is made from the volar to dorsal aspect of the thumb metacarpal stump, elevating radial
and ulnar skin flaps. The flaps are thinned of excess subcutaneous fat if needed. This configuration will
accommodate the triangular plantar and dorsal skin segments provided by the toe flap, while providing needed
coverage on the radial and ulnar aspects of the toe. Dorsally, the incision is extended proximally enough to
provide access to the EPL stump, the radial artery in the snuffbox, and the cephalic vein. Volarly, the incision
is extended proximally enough to access the digital nerves proximal to scar tissue or neuroma. If this is
proximal to the MCP flexion crease, the incision is altered in a zigzag fashion to avoid a postoperative scar
flexion contracture.
a. The bone is resected back to healthy margins. If an arthrodesis is planned (i.e., at the MCPJ level), a cup-
and-cone relationship is usually employed. Whether arthrodesis or extra-articular osteosynthesis is
pursued, we usually utilize a “90-90” intraosseous wiring technique. Intraosseous 24-gauge wire is placed
in the prepared osseous stump with one wire passing volar-dorsal and a second passing radial-ulnar.
2. The flexor tendon is retrieved from the flexor sheath if possible. If it has retracted in the forearm, a
counterincision may be required in the distal forearm to facilitate location and delivery of the tendon distally
through the sheath. In cases where the FPL tendon was avulsed or is unusable, a flexor digitorum sublimis
(FDS) transfer may be performed, typically from the ring finger (FDS IV). In this setting, the tendon is
transected via a small transverse incision at the palmodigital crease of the ring finger, delivered into the distal
forearm, and then rerouted radially (dorsal to the medial nerve) into the FPL sheath.
a. The flexor hallucis longus (FHL) tendon attached to the toe should be long enough to perform tenorrhaphy
proximal to the thenar region. The proximal tendon should therefore be escorted to the operative field at the
level of the MCPJ, prepared with a locking 3-0 Ethibond core suture and tagged for retrieval later in the
case.
The EPL will be available at the MCPJ level if the interconnections with the dorsal extensor hood and extensor
pollicis brevis (EPB) are intact. Otherwise, it may have retracted into the forearm. If this is the case (or if the EPL
was noted to have been avulsed from the injury), an extensor indicis proprius (EIP) transfer can be performed.
The EIP is removed from the retinaculum proximally, rerouted in the subcutaneous plane, and prepared for a
tendon weave repair at the level of the thumb metacarpal.
The digital nerves are resected back to a healthy fascicular pattern and prepared for neurorrhaphy. If the nerves
were avulsed from the injury or deemed unusable, a nerve transfer should be performed using the
common/proper digital nerves to the third web space. These are typically harvested at the PIP level, transposed
subcutaneously, and prepared for neurorrhaphy to the toe digital nerves as distally as possible to minimize
reinnervation delay (Fig. 35-4).
A large cephalic vein or dorsal hand vein is usually readily available and prepared for anastomosis in the same
field of dissection as the artery. The radial artery in the snuffbox is usually employed for end-to-side
anastomosis. Alternatively, the dorsal arch or a dorsal metacarpal artery may be used in an end-to side fashion.
This is particularly helpful if the arterial pedicle is limited in length.
Great toe harvest
1. The incision performed is a “V”-shaped dorsal and plantar incision, which creates dorsal and plantar skin
flaps. The proximal apex of these flaps is centered over the first intermetatarsal space, approximately one
centimeter proximal to the planned osteotomy. The lateral aspect of the incision crosses the first web space at
a midpoint between the 1st and 2nd toes (Fig. 35-5).
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2. The medial aspect of the incision is tailored to create a flap of medial toe tissue that extends distally to include
paronychial and hyponychial tissue. The purpose of this flap is twofold. The medial dissection of the toe
enables this tissue to be excluded from the transferred toe, thus diminishing its size to closer approximate the
girth of a thumb. Through the same medial incision, medial bone may be resected from the distal and/or
proximal phalanx to further debulk the toe. The second purpose of the medial flap is to provide tissue to
enable a tension-free closure of the donor site. For further discussion of the details and modifications of this
medial incision, see “Pearls and Pitfalls.”
3. An extension of the dorsal foot incision is also created roughly along the axis of the first intermetatarsal space
to enable dissection of the arterial pedicle and superficial vein.
4. Deep dissection begins in the first web space to locate the lateral digital artery to the great toe and medial
artery to the second toe. Dissecting proximally the common digital artery can be identified, and the surgeon
can ascertain whether the arterial system is plantar or dorsal dominant. “Dominance” is determined by the
location of the largest pedicle relative to the intermetatarsal ligament. In the majority of cases, arterial supply is
dorsally dominant (14). Harvest of a dorsal dominant pedicle is easier as it is more superficial and rapid to
dissect (Fig. 35-6).
5. Once the supplying blood vessel is identified, dissection should proceed proximally to the desired pedicle
length and vessel caliber. Typically, the artery is dissected to the level of the metatarsal base. While it is
feasible to harvest the vessel more proximally (i.e., to the level of the dorsalis pedis artery), such dissection
may eliminate connections between the dorsal and plantar arterial
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systems, compromising perfusion to the foot. Harvest of the artery to the metatarsal base level will typically
provide enough pedicle length for anastomosis into the snuffbox in the hand.
6. The venous drainage is provided by the superficial veins of the dorsal surface of the foot. Care should be
taken to maintain as many venous channels from the dorsal triangular skin flap of the toe. These will coalesce
into a larger more proximal vein. This vein can be dissected as proximally as desired for additional length and
caliber. Both the artery and vein are dissected but kept in continuity in this initial portion of the case. After
subsequent tissues are elevated, the tourniquet will be released and perfusion to the toe confirmed prior to
ligation of the vessels.
7. The extensor hallucis longus (EHL) is divided at the metatarsal base level and reflected distally. This will
provide enough length for weave into the thumb extensor upon transfer. The extensor digitorum brevis (EDB)
tendon to the great toe is resected and not utilized.
8. The FHL is divided as proximally as possible using the plantar incision described above. This will yield enough
tendon length for tenorrhaphy at the midmetacarpal level in the hand. Harvest of a greater length of the FHL
via counterincisions in the midfoot or ankle is not advisable due to the adherence of the FHL to the flexor
digitorum longus (FDL) tendons at the midfoot decussation of the FDL (master knot of Henry).
9. The medial and lateral nerves to the great toe are plantar and adjacent to the digital arteries. The medial
digital nerve is harvested in its entirety, whereas the lateral digital nerve requires careful intraneural dissection
proximally to separate and preserve the medial digital nerve to the second toe. Both nerves to the great toe
are dissected and divided as proximally as possible to avoid the development of neuromas on the pressure-
bearing metatarsal head region. Sutures are typically used to tag the distal nerves so they may be more easily
located later in the case.
10. There are additional dorsal nerves to the great toe that may be dissected and harvested for coaptation to
either dorsal nerves in the hand or grouped with the plantar digital nerves for coaptation to the larger digital
nerves to the thumb.
11. Once all soft-tissue structures are identified and protected, the plantar skin flap is addressed. This carries
thick plantar fat and excess bulk for the palmar aspect of the hand. This flap should be aggressively debulked
while protecting the neurovascular bundles to maximize aesthetic result.
12. Soft tissue is elevated distally to enable osteotomy at the desired level. Priority should be given to preserving
the MTP joint and capsule for weight bearing (see Indications above). Soft tissue is elevated 5 to 10 mm distal
to the planned osteotomy to accommodate intraosseous wire placement. The osteotomy is performed with a
sagittal saw with copious irrigation.
13. The toe transfer is now attached solely by its single artery and single vein pedicle. The tourniquet is released.
Perfusion to the great toe and the foot is confirmed. The pedicle may now be ligated and harvest completed
(Fig. 35-7).
14. The donor site is closed using the medial skin flap to achieve tension-free closure. If the harvest is performed
at the IPJ or distal aspect of the proximal phalanx, closure may be difficult due to the remaining phalangeal
bone on the foot. In this case, the bone may be further resected (while still preserving the proximal phalangeal
base and MTPJ integrity) and discarded to facilitate closure.
FIGURE 35-4 In this injury, the digital nerves were avulsed from the median nerve in the carpal tunnel. To
address this, the common and proper digital nerves to the third web space were transferred to the thumb. This
provides the benefit of rapid reinnervation from atraumatic nerves coapted close to the digital tip. The patient
should anticipate the donor site deficit inherent to the nerve transfer.
FIGURE 35-5 Markings for the trimmed toe flap (red line) and a standard approach (yellow line). The trimmed
option confers two advantages: (1) soft-tissue flap that facilitates donor site closure (2) reduced girth of the
transferred toe to better approximate the appearance of a thumb.
FIGURE 35-6 Dissection begins in the first web space. When the lateral artery of the medial toe and medial
artery of the lateral toe converge, dorsal/plantar dominance is confirmed and dissection proceeds proximally.
Note the proximally reflected trimmed toe flap (white arrow) and the generous dorsal vein (yellow). Also, note the
generous extensor tendon leash (green arrow) and interosseous wire inserted prior to harvest (orange arrow).
Toe transfer technique: Order of inset: bone, tendon, nerve, vessels

1. Osteosynthesis: (Fig. 35-8) Upon transfer of the toe to the prepared hand, attention is first directed toward
restoring appropriate length. With the digits extended and thumb adducted, the thumb length is assessed. The
thumb tip should reach a point approximately 10 mm proximal
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to the proximal phalangeal (PIP) joint line. Excessive length will result in a far more noticeable deformity than a
slightly shorter thumb. Bone edges are trimmed to establish this desired length, preferentially by resecting
additional bone from the toe rather than the thumb stump.
a. Attention is then directed to rotational alignment. With the hand in repose, the volar surface of the thumb
should be facing the small finger. One should anticipate that active opposition postoperatively will achieve
additional pronation toward the thumb. If the surgeon feels that the trauma may limit the patient's ability to
pronate actively, he or she may elect to provide greater pronation than described here via the position of
osteosynthesis.
b. Intraosseous wires are then positioned in the sagittal and coronal planes (relative to the thumb). The wire
loops are secured via twist knots positioned dorsally and radially. A rapid technique for the passage of the
wires is described below in Pearls section.
2. Tendon
a. EHL is woven to the EPL as securely as possible with the thumb in full extension.
b. A tenorrhaphy is performed between the FHL and the FPL using standard locking core suture repair
techniques. The suture that was affixed to the FPL in preparation of the hand is utilized, and the knot is
secured inside the repair site. If the FPL or EPL is not adequate, FDS IV and EIP transfers (respectively)
may serve as substitutes.
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3. Nerves: At this point in the case, the microscope is brought into the field. Proper digital nerves are coapted in
a tension-free manner using microsuture. Additional prepared dorsal toe sensory branches may be included in
these repairs if dorsal sensory nerve stumps are not available in the hand.
4. Vessels: Both venous and arterial anastomoses occur in the same surgical field over the snuffbox. This may
be accessed by continuing the dorsal incision from the thumb or, more commonly, via a counterincision. If the
counterincision is employed, a generous subcutaneous tunnel should be created to avoid tension or pressure
on the vessels.
a. The arterial repair may be performed end to side into the radial artery or end to end into one of its branches
(i.e., metacarpal arteries or the dorsal arch) according to the surgeon's preference. While we usually use
the former, there is no demonstrated patency superiority of one technique over another (15,16).
b. Venous anastomosis is performed into the cephalic vein or one of its branches end to end. Clamps are
released, and reperfusion is observed.
FIGURE 35-7 The prewired, trimmed, harvested toe at the level of the metatarsophalangeal joint from dorsal to
volar: extensor tendon (EHL), vein (V), artery (MTA), medial and lateral proper digital nerves (N), and flexor
tendon (FHL). Note: the dorsal and volar flaps are closed prior to flap harvest.
FIGURE 35-8 Osteosynthesis. The metacarpophalangeal joint was fused due to preexisting joint destruction
using “90-90” interosseous wiring. Rotational alignment is assessed intraoperatively and individualized based on
anticipated functional impairment (see Toe transfer technique: osteosynthesis).
Skin is then loosely approximated with the volar and dorsal toe triangular flaps inserting into the volar and dorsal
incisions in the hand. If additional coverage is required, skin grafting may be performed. This is preferable to
closure of the skin with tension.
PEARLS AND PITFALLS

Due to the many steps of the procedure, managing tourniquet time efficiently is important. In the authors'
experience, the least predictable portion of the procedure is the osteosynthesis. Preoperative x-rays of the
injured and contralateral thumbs and harvest foot may facilitate planning to rapidly establish correct skeletal
length.
Additional time can be saved by efficient placement of intraosseous wires. A technique to facilitate this is to
create the tunnels with a cannulated spinal anesthesia needle. After removal of the obturator, the plastic hub
is removed with a wire cutter. The surgeon then insures that the size needle selected will accommodate the
gauge of intraosseous wire to be utilized. The spinal needle may then be loaded in the wire driver and passed
through the bone. The intraosseous wire is then introduced into the open end of the spinal needle, and it is
withdrawn from the bone, escorting the intraosseous wire through the tunnel. This avoids the often frustrating
task of threading the wire through a bone tunnel manually.
The aesthetic appearance of the recreated thumb is influenced by length, rotation, girth, and the morphology
of the nail complex. Length and rotation are insured by preoperative planning and fixation techniques
described above (see Toe Transfer technique: Osteosynthesis). Breadth of the thumb is diminished to
approximate the contralateral thumb by resecting medial soft tissue and bone as described above (see
Harvest of Great Toe). The nail complex of the great toe is similar to the thumb in length, color, and convexity
but is usually considerably wider. This can be diminished by assessing the difference in width between the
transferred toe nail and the contralateral thumbnail. The difference can be excised longitudinally by three
techniques:
1. After the toe has healed, the nail bed can be resected in a second stage procedure. This is performed at
the radial or ulnar margin of the nail bed (rather than on midline) to minimize the risk of nail bed deformity.
2. At the time of the transfer, an incision can be made in the nail bed (sterile and germinal matrix) and
hyponychium separate and parallel to the medial toe debulking incision. This achieves both goals of girth
and nail bed reduction, but may risk the viability of the intervening skin bridge.
3. At the time of the transfer, the medial incision and nail bed incisions may be made in continuity by crossing
the eponychial fold at the medial “corner” between the eponychia and paronychia. This facilitates
aggressive bone, skin (including excess eponychia and hyponychia), and nail resection through the same
dissection field. Great care is taken to meticulously reapproximate the eponychial margin to maximize
aesthetic appearance (Fig. 35-9).
The feeding vessel to the great toe flap is dorsal dominant the majority (70%) of the time. In 10% of cases, the
plantar and dorsal systems are equivalent, and in 30%, the primary blood supply is plantar. Dissection can be
more challenging when the source vessel is plantar, as the artery usually courses medially and deep in the
dissection field (14).
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FIGURE 35-9 A,B: Alternative trimmed toe markings (red dashed line): At the time of the transfer, the medial
incision and nail bed incisions may be made in continuity by crossing the eponychial fold at the medial “corner”
between the eponychia and paronychia. This facilitates aggressive bone, skin (including excess eponychia and
hyponychia), and nail resection through the same dissection field. C: Early postoperative appearance.
The hand is protected with a well-padded postoperative thumb spica splint for two weeks followed by a
removable thermoplast thumb spica for four additional weeks. Postoperative therapy is initiated as rapidly as
possible taking into consideration the osseous fixation, flexor tendon repair, and possible skin graft requirements.
The foot is immobilized for the first 4 days with a bulky posterior ankle splint. This is exchanged for a cam boot,
and weight bearing is initiated and progressed as tolerated.
As with any free flap, skilled and vigilant postoperative monitoring is critical. Any changes in Doppler findings and
clinical examination should warrant special consideration for surgical exploration. Patients are not fed for the first
24 hours after surgery and advanced thereafter if no surgical exploration is needed. Caffeine and caffeine-
containing foods like chocolate are prohibited for three weeks postoperatively because of speculation that these
foods may induce vasoconstriction and platelet aggregation (17).
Patients are admitted to the hospital for vascular monitoring for 4 days. During this period, the arm is wrapped in
a heating blanket to minimize vasoconstriction. Enteric-coated aspirin (325 mg) is given orally once daily for three
weeks as well as routine low molecular weight heparin for venous thrombosis prophylaxis while in the hospital.
COMPLICATIONS
Recipient Site
The loss of a free toe transfer is a dreaded complication due to the considerable cosmetic deformity of the
donor site and potential for functional impairment. Akin to other free flap procedures, however, vascular
thrombosis is uncommon (less than 5%) in great toe transfer (3). When identified,
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prompt reexploration can salvage a thrombosed flap in most cases (18). As a result, complete loss of toe
transfers is rare (19,20).
A functional complication often seen is stiffness at the IPJ or MCPJ or both. This generally does not warrant
surgical treatment as the functional success of the recreated thumb is more related to the passive and
active range of motion of the CMCJ. However, if rehabilitation is limited by functional impairment, secondary
procedures have been described to improve mobility (21).
Excessive thumb girth or nail width can be addressed in subsequent debulking procedures (22,23).
Revision surgery can be avoided by aggressive debulking at the time of the transfer.
Donor Site
Resection of metatarsal bone may lead to instability in the donor foot in the short term, as described above.
This can be avoided by restricting the harvest to the phalangeal level and preserving the MTPJ and its
capsular structures. Recently, long-term effects of toe transfers on the donor foot have been examined.
Kotkansalo et al. revealed that over 90% of a series of 80 feet patients had no complaints or minor
complaints in the donor site 16 years after transfer. In that series, cold intolerance and exertional pain were
the most commonly reported complaints. Maloney et al. describe a pattern of painful neuromas of the
superficial and deep peroneal nerves and the common plantar digital nerve to the first web space after toe
transfer. These are managed by conventional methods including neuroma resection and nerve implantation
into muscle. Anatomically, callus formation and aesthetic deformity may be expected.
RESULTS
It has been shown that toe transfers distal to the IPJ demonstrate excellent functional outcomes. Chung and
Wei (26) demonstrated that the overall function after toe transplant is lower but comparable to the uninjured
contralateral hand using the Michigan Hand Outcomes Hand Questionnaire. In the same population,
aesthetic appearance, return to work, function, and satisfaction were significantly greater than in
unreconstructed amputees. Using the Jebsen-Taylor test, no significant difference was observed in
dexterity of the toe transfer and unaffected hand. A thumbless hand, by contrast, was significantly less
dexterous than was the unaffected hand. Dynamometric measurements of the toe-transferred hands
demonstrated grip strength and pinch measurements comparable to unaffected hands. SF-36 survey scores
demonstrated significant improvement in emotional wellbeing and vitality in patients who underwent toe
transfer versus amputation.
Lee and Buncke (8) reviewed 161 great toe transplantations over a 32-year period. Of those, four failed
(2.5%), and long-term follow-up was obtained on 73 patients. They observed a mean two-point
discrimination of 8 mm with 5 mm of protective sensation. In their study, MPJ ROM was 44 degrees (63% of
the contralateral side) and IPJ ROM was 40 degrees (59%). Grip and pinch strength were 77% and 67% of
the contralateral side.
With refinements in technique, the cosmetic result of the transplanted toe is quite favorable and symmetric
to the unaffected thumb (Fig. 35-10).
FIGURE 35-10 The relative circumferential symmetry of the thumb and toe following trimmed toe transfer. A
well-designed reconstruction may provide near-normal appearance.
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REFERENCES
1. Valauri FA, Buncke HJ: Thumb reconstruction—great toe transfer. Clin Plast Surg 16: 475-489, 1989.
2. Wei FC, Chen HC, Chuang CC, et al.: Microsurgical thumb reconstruction with toe transfer: selection of
various techniques. Plast Reconstr Surg 93: 345-351, 1994.
3. Lin PY, Sebastin SJ, Ono S, et al.: A systematic review of outcomes of toe-to-thumb transfers for isolated
traumatic thumb amputation. Hand (N Y) 6(3): 235-243, 2011.
4. Brown CJ, Mackinnon SE, Dellon AL, et al.: The sensory potential of free flap donor sites. Ann Plast Surg
23: 135-140, 1989.
5. Jeng C, Michelson J, Mizei M. Sensory thresholds of normal human feet. Foot Ankle Int 21: 501-504,
2000.
6. Erdemir A, Hamel AJ, Fauth AR, et al.: Dynamic loading of the plantar aponeurosis in walking. J Bone
Joint Surg Am 86-A(3): 546-552, 2004.
7. Lin CH, Mardini S, Lin YT, et al.: Osteoplastic thumb ray restoration with or without secondary toe transfer
for reconstruction of opposable basic hand function. Plast Reconstr Surg 121: 1288-1297, 2008.
8. Lee CK, Buncke GM: Great toe-to-thumb microvascular transplantation. Clin Plast Surg 34(2): 223-231,
2007.
9. Wei FC, Chen HC, Chuang CC, et al.: Reconstruction of the thumb with a trimmed-toe transfer technique.
Plast Reconstr Surg 82(3): 506-515, 1988.
10. Dellon AL: Sensory recovery in replanted digits and transplanted toes: a review. J Reconstr Microsurg
2(2): 123-129, 1986.
11. Ma HS, El-Gammal TA, Wei FC: Current concepts of toe-to-hand transfer: surgery and rehabilitation. J
Hand Ther 9: 41-46, 1996.
12. Woo SH, Kim JS, Seul JH: Immediate toe-to-hand transfer in acute hand injuries: overall results,
compared with results for elective cases. Plast Reconstr Surg 113(3): 882-892, 2004.
13. Chu NS, Wei FC: Recovery of sensation and somatosensory evoked potentials following toe-to-digit
transplantation in man. Muscle Nerve 18: 859-866, 1995.
14. Gordon L. Toe-to-thumb transplantation. In: Green DP, ed. Operative hand surgery. Vol. 1, 3rd ed. New
York, NY: Churchill Livingstone, 1993: 1253-1282.
15. Samaha FJ, Oliva A, Buncke GM, et al.: A clinical study of end-to-end versus end-to-side techniques for
microvascular anastomosis. Plast Reconstr Surg 99: 1109, 1997.
16. Miyamoto S, Takushima A, Okazaki M, et al.: Relationship between microvascular arterial anastomotic
type and area of free flap survival: comparison of end-to-end, end-to-side, and retrograde arterial
anastomoses. Plast Reconstr Surg 121: 1901, 2008.
17. Rein D, Paglieroni TG, Pearson DA, et al.: Cocoa and wine polyphenols modulate platelet activation and
function. J Nutr 130(8S, Suppl): 2120S-2126S, 2000.
18. Cheng MH, Wei FC, Santamaria E, et al.: Single versus double arterial anastomoses in combined
second- and third-toe transplantation. Plast Reconstr Surg 102: 2408-2412, 1998.
19. Yim KK, Wei FC, Lin CH: A comparison between primary and secondary toe-to-hand transplantation.
20. Gu YD, Cheng DS, Zhang GM, et al.: Long-term results of toe transfer: retrospective analysis. J Reconstr
Microsurg 13: 405-408, 1997.
21. Yim KK, Wei FC: Secondary procedures to improve function after toe-to-hand transfer. Br J Plast Surg
48: 487-491, 1995.
22. Wei FC, Chen HC, Chuang DC, et al.: Aesthetic refinements in toe-to-hand transfer surgery. Plast
Reconstr Surg 98(3): 485-490, 1996.
23. Zhao J, Tien HY, Abdullah S, et al.: Aesthetic refinements in second toe-to-thumb transfer surgery. Plast
Reconstr Surg 126(6): 2052-2059, 2010.
24. Kotkansalo T, Elo T, Luukkaala T, et al.: Long-term effects of toe transfers on the donor feet. J Hand
Surg Eur Vol 39(9): 966-976, 2014.
25. Frykman GK, O'Brien BM, Morrison WA, et al.: Functional evaluation of the hand and foot after one-stage
toe-to-hand transfer. J Hand Surg Am 11(1): 9-17, 1986.
26. Chung KC, Wei FC: An outcome study of thumb reconstruction using microvascular toe transfer. J Hand
Surg Am 25(4): 651-658, 2000.
27. Maloney CT Jr, DeJesus R, Dellon AL: Painful foot neuromas after toe-to-thumb transfer. J Hand Surg
Am 30(1): 105-110, 2005.
Chapter 36
Surgical Release and Reconstruction for Digital Syndactyly
Carley B. Vuillermin
Peter M. Waters
Syndactyly is the failure of the separation of adjacent digits. It is one of the most common congenital hand
malformations, with an occurrence of 1 in 2,000 to 2,500 births, although the true incidence is unknown as many
partial syndactylies never come to medical attention.
Syndactyly is commonly an isolated abnormality. It may be inherited as an autosomal dominant trait, associated
with toe syndactyly, less commonly polydactyly, or as part of a syndromic presentation. Syndromes associated
with syndactyly are numerous and include Apert's syndrome, Timothy syndrome, and Poland's syndrome. Their
identification is important due to associated diagnoses including arrhythmias with rare Timothy's syndrome and
increased complexity of reconstruction with central polysyndactyly.
Amniotic band disruption sequence may present with syndactyly. However, this is not a primary failure of the
digits to separate as in all other forms of syndactyly. Amniotic band disruption sequence is an initial normal
separation of digital rays that secondarily become syndactylized as part of the banding. On exam, this is evident
by sinuses between digits that can be probed and often is associated with acrosyndactyly, distal amputations,
and deep skin bands. Syndactyly occurs most commonly between the long and ring fingers (50%), followed by
the ring-small (30%), index-long (15%), and least commonly thumb-index (5%) web spaces. Syndromic
syndactyly is more likely to present involving multiple web spaces and, at times, unusual web spaces such as
fourth web space in Timothy's syndrome (Fig. 36-1).
Syndactyly is classified according to clinical and radiographic findings, by the degree of webbing (complete or
incomplete), the presence of bony fusion (simple or complex), and/or other bony anomalies (complicated) (Table
36-1). The underlying skeletal and neurovascular development may only be apparent at the time of surgery, but
generally, the more complex the involvement, the more likely there will be neurovascular anatomic abnormalities.
In all cases of syndactyly, the reconstruction centers around a deficit of skin. However, it is not only the skin that
is affected, and each element needs to be addressed when planning and undertaking surgical care.
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FIGURE 36-1 The prevalence of web space involvement in cases of simple and complex syndactyly. (From
Waters PM, Bae DS: Pediatric hand and upper limb surgery: a practical guide. Philadelphia, PA: Lippincott
TABLE 36-1 Classification of Syndactyly
Extent of webbing Incomplete Syndactyly does not extend to fingertips
Complete Syndactyly extends to fingertips
Presence of bony abnormalities Simple Soft-tissue connection only
Complex Synostosis
Complicated Bony malformation
INDICATIONS FOR SURGERY

Most complete syndactylies warrant surgical release to achieve
Maximum independent digital function
Increased grasp and pinch—especially for index-thumb syndactyly
Prevention of angular deformity—particularly border syndactyly
Ring and glove wear
Contraindications for surgery include
Inadequate skeletal stability
Hypoplastic extrinsic tendons so independent function is not feasible
Insufficient vascular supply
Develop a preoperative plan to address each aspect.
Skin
Nail and nail fold
Neurovascular bundles
Tendons and ligaments
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Bony architecture
Preoperative assessment
Clinical examination
Health status of associated medical conditions
Web spaces affected—the normal web space anatomy should be appreciated. The index-middle and ring-
small web are U-shaped and the middle-ring V-shaped. Each web slopes gently down at an angle of 45
degrees from the base of the proximal phalanx dorsally to the middle of the proximal phalanx volarly.
Individual digits. Assess for independent movement and skin creases. An absence of skin creases
increases the likelihood of hypoplastic extrinsic tendons and deficient joint development. A digital Allen's test
may be performed on the free border of the digit or previous separated side of a digit to assess for
independent digital arterial supply.
Radiographs of the affected hand/s should be obtained preoperatively and assist with classification and
anticipating surgical needs.
Review of prior operative reports to assess for vascular anomalies or ligations that may have been
performed.
Considerations for the timing of surgery include, but are not limited to: influence of one conjoined digit on
another, associated clinical conditions and general health status. Generally, surgery for these congenital
differences is rarely performed before age 6 months because of digital size and anesthetic considerations.
However, digital separation may be delayed until school age or beyond, depending on individual patient
circumstances.
Anesthesia becomes safer with age. Although the effects of anesthesia on the developing brain are still
being investigated, physiologically, the risk of anesthesia decreases after 6 months of age and, in all cases
except acrosyndactyly with vascular compromise surgery, should be deferred until after this age. With
growth, involution of neonatal adiposity occurs and neurovascular bundle size increases. Many surgeons
defer separation of nonborder digits until 18 months of age although we frequently do surgery between 6
and 12 months of age.
Border digits have inherent differences in length and growth and influence hand function to a greater
degree than central web spaces. Progressive deformity is an indication for earlier release and can be
contemplated from 6 to 12 months of age or even early depending on the degree of deformity. In the very
young, distal release alone to improve digital alignment can be performed with more complete
reconstruction later.
Many families will request early surgical release and this can be considered by experienced surgeons but
should not be the sole determinant of timing. Safety should always be the first priority.
Planning sequence of syndactyly releases.
When multiple webs are affected, then staged surgery is almost always preferable.
Operating on both sides of a digit risks compromising vascularity and is rarely appropriate. Congenital
differences in vascular anatomy increases this risk.
Border digits should be prioritized due to the potential for angular deformity.
When all digits and web spaces are involved, the thumb-index and middle-ring webs are addressed first
followed by index-middle and ring-small secondarily. However, if significant angular deformity exists in both
first and fourth web spaces, then thumb-index and ring-small may be initially addressed together. This will
result in three surgical encounters being required.
When index through small syndactylies occur, the index-middle and ring-small webs are initially addressed
with staged surgery to the middle-ring web.
Determining the need for graft.
Graft is almost always required for syndactyly distal to the proximal interphalangeal joint—it is a condition of
relative skin deficiency.
Partial syndactyly proximal to the proximal interphalangeal can more readily be addressed with graftless
techniques.
Graftless techniques in complete syndactyly have been described. Such surgery requires digital defatting,
altered flap techniques and have yet to gain widespread use in pediatric complete syndactyly
reconstruction.
Selecting graft donor location: Ideally from an inconspicuous location, well matched for color and does not
bear hair in the adult. Full-thickness skin grafts are almost always used because they are more durable and
contract less than do split-thickness grafts.
Groin. The most traditional location and, in terms of being inconspicuous, is the most ideal. However, groin
skin has more of a tendency to hyperpigment with age, especially in darkerskinned individuals, and if taken
too medially, it will contain hair follicles and grow hair after puberty. Graft harvesting should be kept well
lateral to the femoral artery to avoid this. Staying more central in abdominal creases can also be
inconspicuous with less risk of hair bearing later.
Antecubital fossa. It is more conspicuous than groin graft but better matched for color and a skin crease
harvest site minimizes the clinically apparent scarring. It also involves single operative extremity for ease of
postoperative care and a smaller volume of graft can be taken than from the groin.
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Wrist flexion crease. It provides the smallest volume of graft but also is well matched to color with less
hyperpigmentation. Sufficient graft for one to two webs can readily be obtained. As it is adjacent to the
surgical reconstruction, graft harvest and surgical closure are more difficult simultaneously. Some surgeons
have concerns regarding social implications of scars across the flexor aspect of the wrist in terms of suicide
implications, but keeping the incision in the wrist crease incision minimizes clinical scarring.
Donor tissue from excised parts utilized where the child has other congenital anomalies, most commonly
polydactyly of the upper or lower extremity. Syndactyly release is frequently timed with other surgeries using
skin harvested from parts that would be otherwise discarded.
Hyaluronic acid scaffold. A new promising technology. Only 2-year follow-up data are available.
TECHNIQUE
Syndactyly release incisions are planned so that the new web is composed of local flaps of native skin with intact
vascularity as opposed to skin grafts. The incisions on the sides of the fingers were frequently in Z-plasty
angulation to minimize the effects of graft and scar contraction during growth.
COMPLETE SYNDACTYLY RELEASE

The patient should be supine on the operating table. A hand table is used throughout the procedure. For small
children, they may be angled on the operating table so that their upper extremity and head are supported on the
hand table and the hand centered to the surgeon. A nonsterile tourniquet or sterile Esmarch bandage tourniquet
may be used. The limb is prepped and draped freely. If a graft harvest site outside of the extremity is selected,
this should also be prepped and draped. Be certain that the natural inguinal skin crease is marked if using groin
graft so as to appropriately orient the graft to minimize scarring.
Consider placing nylon traction sutures in the digital pulps adjacent to the webs to be released to minimize
tissue handing and place the hands of the assistant retracting outside of the working operative field. Skin flap
marking and elevation
Prior to insufflation of the tourniquet, mark out the skin flap incisions (Fig. 36-2).
Middigital lines on each digit adjacent to the space to be released.
Dorsal rectangular flap measuring two-thirds the length of the proximal phalanx to recreate the commissure—
the base of this flap is at the level of the metacarpophalangeal joint and extends to the midline of the digit. Its
distal end should be “V”-shaped to key into the palmar inset point.
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Palmar inset point. A “V” just proximal to the level of the proximal digital flexion crease. This will be distal to the
base of the dorsal flap to allow for the 45-degree downsloping commissure.
Reciprocal interdigitating zigzag flaps with their apices alternating at the level of the skin creases for the joints
and midphalanges. Ensure that reciprocal markings are made on the palmar aspect so that the flaps
interdigitate—use lines around the digit margins to denote the apices and dotted lines for the bases of the
triangles to assist in appropriate placement (Fig. 36-3).
Mark out the flaps to recreate the nail fold if necessary at this same point to avoid truncation during separation
(discussed in detail later).
Exsanguinate the limb and elevate the tourniquet.
Start by incising the digital nail fold flaps followed by the dorsal rectangular and digital flaps and then volar
digital flaps (Fig. 36-4).
Keep the flaps full thickness with a small amount of subcutaneous fat to maximize vascularity. Use sharp
dissection and skin hooks. Avoid grasping the tissues with forceps. Preserve dorsal veins where possible.
In complex syndactyly, use a knife or sharp narrow bone-cutting rongeur to separate the distal synostosis.
Work in the midline between the digits from distal to proximal separating the fibrous connections with a
combination of blunt and sharp dissection. Avoid straying from the midline in order to avoid neurovascular
injury.
FIGURE 36-2 Diagram depicting the author's preferred landmarks and approach to marking of incisions for
syndactyly release. (From Waters PM, Bae DS: Pediatric hand and upper limb surgery: a practical guide.
FIGURE 36-3 Clinical photograph with incisions marked out for release of simple complete syndactyly. A: Dorsal
aspect. B: Volar aspect. (From Waters PM, Bae DS: Pediatric hand and upper limb surgery: a practical guide.
FIGURE 36-4 Nail fold and dorsal rectangular and digital incisions completed.
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FIGURE 36-5 Neurovascular bundle bifurcation in partial syndactyly, placed in a more distal location.
Neurovascular bundles
Identify and protect the neurovascular bundles. The bifurcations are commonly more distal in digits with
syndactyly (Fig. 36-5).
If the bifurcation of the digital nerve is distal to the vascular bifurcation, the epineurium can be incised and the
fascicles gently separated using the back of a No. 15 blade at its tip (or Beaver blade).
It may be necessary to ligate one digital artery. If necessary to ligate the artery, select the most hypoplastic
vessel, the vessel to the nonborder digit, or digit without adjacent web space syndactyly. An occlusion test
with release of the tourniquet should be performed if there is any doubt regarding vascularity prior to formal
ligation. If there is still doubt, then it is safer to incompletely release the web rather than risk viability of the
digit.
Closure
Closure is performed with 6-0 or 5-0 chromic sutures without tension.
Once the release is complete, bring the dorsal rectangular flap down and suture it with interrupted sutures to
the volar inset point to recreate the commissure.
Next, interdigitate the volar and dorsal skin flaps and suture with simple interrupted sutures (Fig. 36-6).
This will generally leave two areas proximally requiring full-thickness grafting.
Use the suture or glove packet to template the areas that require grafting, labeling each graft according to
location and placing a dot distal for an orientation marker. For example, on the radial side of the ring finger,
label the template “RR” or ulnar side of the middle finger “UM.” This is particularly important when multiple
webs are being addressed.
Arrange all templates over the graft site and determine the configuration that will yield a graft harvest that is
the minimum surface area, usually the ideal dimensions of an ellipse being three times as long as it is wide.
Outline all of your grafts prior to harvesting your full-thickness graft and label as the templates. This ensures a
proper tension and geometry when you suture the grafts in place. Pieces of graft may then be either harvested
together and secondarily separated or individually taken. Make sure that any fat is removed from the deep
surface.
Close the donor site with 4-0 to 5-0 Vicryl if dermal detensioning is required and then 4-0 to 5-0 Monocryl
subcuticularly depending on age.
Suture your graft at each apex of the recipient site with simple stitches, and then use continuous sutures along
the margins (Fig. 36-7).
Place bolsters of Xeroform followed by moist gauze that have been cut to the shape of your graft sites. You
may secure them with quarter-inch Steri-Strips that just reach onto the native skin and do not encircle the digit
or simply place mild tension on gauze wrap over the moist cotton. Be certain not to impair distal vascular flow
in or out with too much tension.
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Place additional gauze fluffs between the digits until the fingers are well padded and secure with a Kling
bandage taking great care during all steps of dressing application to avoid circumferentially constrictive
dressings.
Release the tourniquet and ensure that the fingertips are well perfused. Release the dressings and some of
the closing sutures if any doubt exists.
The arm is then dressed in a long arm mitten cast or bulky soft-tissue dressing depending on age and
protection needed for graft survival.
FIGURE 36-6 Volar view following interdigitation of skin flaps.

FIGURE 36-7 Dorsal view following interdigitation of skin flaps and completion of fullthickness grafting. (From
Waters PM, Bae DS: Pediatric hand and upper limb surgery: a practical guide. Philadelphia, PA: Lippincott
Nail fold reconstruction (synonychia)
The joined nail plate is readily divided longitudinally precisely in the midline between the two digits. Usually,
this is evident on x-ray and more proximal dissection. However, the nail fold (eponychium) needs to be
recreated. It is best created using local tissue flaps from the digital pulp. On occasion, composite skin and fat
grafts are needed.
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Interdigitating Buck-Gramcko flaps are ideal. Each limb should be of sufficient length to reach to the base of
the nail plate (Fig. 36-8).
If only one nail fold can be recreated with local tissue, the radial side of the ulnar digit should be prioritized for
future lateral key pinch. This occurs most commonly in small or previously operated digits.
Other options include full-thickness pinch grafts from the hypothenar or thenar eminences or free plantar toe
pulp grafts.
FIGURE 36-8 A: Schematic diagram depicting interdigitating Buck-Gramcko flaps for synonychia reconstruction.
B: Clinical example. (Part A from Waters PM, Bae DS: Pediatric hand and upper limb surgery: a practical guide.
Complicated syndactyly and hypoplastic skeletal elements
Have a high index of suspicion for the potential of hypoplastic elements with complicated syndactyly and stiff
digits without flexion or extension creases.
If uncertain that there is sufficient extrinsic tendon function or stability of a digit, then plan out skin flaps and
perform exploration of the digit to be reconstructed prior to committing to separation. These surgeries are often
performed later in life or not at all depending on findings with growth.
After marking of the planned skin flaps, incise only the skin flaps overlying the area of concern and explore the
skeletal elements.
Proceed with syndactyly reconstruction only once sufficiently satisfied that it will result in a functional stable
digit.
Hypoplastic elements and skeletal deficiency may contraindicate the separation.
PARTIAL SYNDACTYLY RELEASE

May commonly be performed without the need for graft.
The same principles apply to partial syndactyly release as in complete syndactyly release, particularly
concerning resurfacing the commissure with vascularized native skin and avoiding longitudinal scars that will
cause digital contractures with growth.
If the partial syndactyly is proximal to the proximal interphalangeal joint, then graftless techniques are usually
readily achieved.
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More distal incomplete syndactylies can be managed with flap planning and release the same as for complete
syndactyly.
Many different techniques have been described for graftless partial syndactyly release (Fig. 36-9).
Our preferred technique is double-opposing Z-plasties. All limbs should be of equal length. Fullthickness flaps
are created, and care is taken to protect the underlying neurovascular bundles. Once released, the flaps will
tend to naturally rotate into position and are then sutured in place with 6-0 chromic sutures.
FIGURE 36-9 Partial syndactyly reconstruction.
SYNDACTYLY RELEASE IN SPECIAL CIRCUMSTANCES

The same principles also apply in the more complex hand. However, both the pre- and intraoperative decision
making will be more difficult.
First web space syndactyly release (thumb-index)
There is a greater area to be resurfaced and greater implications of secondary web contracture. The more native
skin used, the more supple the web will be. Ideally, the entire web will be resurfaced with a single vascularized
flap, and in these circumstances, a dorsal rotation flap is utilized.
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A 2- or 4-part Z-plasty can be used in mild first web space syndactyly where lesser degrees of deepening are
required. We have never regretted deepening a first web space that caused limited grasp between the index
finger and thumb (Fig. 36-10).
Symbrachydactyly
FIGURE 36-10 First web space deepening utilizing a dorsal rotation advancement flap. A: Incisions for first web
space release and dorsal advancement flap. B: Intraoperative clinical photograph depicting the advancement
flap with the web resurfaced with native vascularized tissue and suture line on the volar aspect of the palm.
(From Waters PM, Bae DS: Pediatric hand and upper limb surgery: a practical guide. Philadelphia, PA:
Symbrachydactyly is characterized by short digits with variable degrees of syndactyly. Symbrachydactyly is often
associated with Poland's syndrome (hypoplasia or absence of the pectoralis major muscle). Planning of flaps is
carried out as for complete or partial syndactyly release previously described. The temptation to make longer-
appearing digits by setting the web proximal to the metacarpal head dorsally and the proximal digital crease
volarly should be avoided. Phalangization of the metacarpal is unsightly and does not necessarily improve
function.
Complex Synpolydactyly
Forms a subset of complicated syndactyly and is associated with much higher complexity pertaining to
intraoperative decision making. Complex synpolydactyly forms a subset of complicated congenital differences
and requires advanced preoperative and intraoperative decision making. Subtotal tissue separation, resulting in
what some call a “super digit” formed by retaining skeletal elements that are codependent for stability, is
preferable to creating an unstable digit. Angular deformities, and other complications, occur more frequently in
these patients.
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Apert's hand (acrocephalosyndactyly)
Apert's syndrome presents with a combination of syndactyly, cranial synostoses, and midface hypoplasia. The
central syndactylies are commonly complex and the border syndactylies simple. The hand formation has been
subdivided by Upton into type I hands (spade hand) with syndactyly of digits two through five; type II hands
(mitten hand) with first through fourth web space syndactyly; and type III hands (rosebud hand) with tight
grouping of all digital tips including complex syndactyly of the thumb. The higher the classification subtype, the
more complex the reconstruction. At times, it is not possible to create 4 webs; the reconstructive goal is to
recreate a first web space for opposition and release the small finger for wider grasp. Symphalangism in Apert's
syndrome is not a contraindication to separation.
PEARLS AND PITFALLS

When starting out, select partial and simple complete syndactylies.
Check your planned flaps to ensure that they are reciprocating and will interdigitate after release.
Always be prepared to take a skin graft.
Approach syndromic and complicated syndactyly with a greater degree of caution.
The patients are placed in either a bulky well-padded soft bandage or long arm mitten cast for 2 to 3 weeks. If
skeletal alignment is performed, then small pin fixation is used with cast protection for longer (3 to 4 weeks). No
change of dressing is performed before that time. At follow-up in the office, removal of the dressing, and if
appropriate pin, is performed with debridement of surgical sites. Daily bathing and dressing changes will resolve
residual eschar over the ensuing week. After that, activity as tolerated is begun. At times, nighttime scar molds
are used for 3 to 6 weeks after complete wound healing if there is any skeletal involvement.
COMPLICATIONS
Web creep It is minimized by careful surgical technique. Ensure that flaps are designed to resurface the
commissure with native skin and use full thickness, rather than split-thickness grafts. Web creep can
occur with growth of the hand and may not appear until adolescence.
Graft failure Complete graft failure is uncommon. Even if partial failure occurs, parts of the graft are
likely to have taken. Avoid debridement where possible and observe.
Hypertrophic scarring For less severe hypertrophic scarring and partial graft loss, scar molds are
utilized. Patients who exhibit subtle overgrowth of the syndactylized digits have a propensity for keloid
scarring and may benefit from methotrexate treatment in the postoperative period, although this is
uncommon. If hypertrophic scarring causes digital malalignment over time, then repeat surgery is
indicated later.
Digit loss Uncommon and careful technique should avoid this catastrophic complication. Meticulous
identification and protection of the vascular bundle on the volar side of the digit will minimize this risk.
Always release the tourniquet prior to covering digits with the definitive dressing or cast. If there is any
sign of embarrassment of a digit, ensure that the dressing is not constrictive and release some of the
closing sutures. Do not leave the operating room until circulation is without risk of compromise.
RESULTS
Syndactyly reconstruction is both common and rewarding. Independent digital function is expected. Simple
complete syndactyly reconstruction rarely requires repeat surgery even over time. More complex syndactyly
reconstruction is also rewarding with limited rate of complications. Setting expectations of long-term function
with hypoplastic digits is important. Remember the brain is smarter than the hand, so even with less than
ideal digits, these children will function at the highest level.
RECOMMENDED READING
1. Eaton CJ, Lister GD: Syndactyly. Hand Clin 6: 555-576, 1990.
2. Deunk J, Nicolai JP, Hamburg SM: Long-term results of syndactyly correction: full-thickness versus split-
thickness skin grafts. J Hand Surg Br 28: 125-130, 2003.
3. Ekerot L: Syndactyly correction without skin-grafting. J Hand Surg Br 21: 330-337, 1996.
4. Golash A, Watson JS: Nail fold creation in complete syndactyly using Buck-Gramcko pulp flaps. J Hand
Surg Br 25(1): 11-14, 2000.
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5. Landi A, Garagnani L, Leti Acciaro A, et al.: Hyaluronic acid scaffold for skin defects in congenital
syndactyly release surgery: a novel technique based on the regenerative model. J Hand Surg Eur Vol 39(9):
994-1000, 2014.
6. Percival NJ, Sykes PJ: Syndactyly: a review of the factors which influence surgical treatment. J Hand Surg
Br 14(2): 196-200, 1989.
SYNDACTYLY RECONSTRUCTION IN SPECIAL CIRCUMSTANCES

Partial Syndactyly
7. Shaw DT, Li CS, Richey DG, et al.: Interdigital butterfly flap in the hand (the double-opposing Z-plasty). J
Bone Joint Surg Am 55(8): 1677-1679, 1973.
8. Bandoh Y, Yanai A, Seno H: The three-square-flap method for reconstruction of minor syndactyly. J Hand
Surg Am 22A: 680-684, 1997.
9. Ostrowski DM, Feagin CA, Gould JS: A tree-flap web-plasty for release of short congenital syndactyly and
dorsal adduction contracture. J Hand Surg Am 16(4): 634-641, 1991.
FIRST WEB RECONSTRUCTION

10. Buck-Gramcko D: Syndactyly between the thumb and index finger. In: Buck-Gramcko D, ed. Congenital
malformations of the hand and forearm. New York: Churchill Livingston, 1998: 141-147.
11. Ghani HA: Modified dorsal rotation advancement flap for release of the thumb web space. J Hand Surg
Br 31(2): 226-229, 2006.
12. Sandzen SC: Thumb web reconstruction. Clin Orthop 195: 66-82, 1985.
APERT'S SYNDROME
13. Upton J: Apert syndrome: classification and pathologic anatomy of limb anomalies. Clin Plast Surg 18:
321-355, 1991.
14. Chang J, Danton TK, Ladd AL, et al.: Reconstruction of the hand in Apert syndrome: a simplified
approach. Plast Reconstr Surg 9: 465-470; discussion 471, 2002.
15. Fereshetian S, Upton J: The anatomy and management of the thumb in Apert syndrome. Clin Plast Surg
18: 365-380, 1991.
POLAND'S SYNDROME
16. Ireland DC, Takayama N, Flatt AE: Poland's syndrome. J Bone Joint Surg 58A: 52-58, 1976.
KELOID FORMATION AND METHOTREXATE

17. Tolerton SK, Tonkin MA: Keloid formation after syndactyly release in patients with associated
macrodactyly: management with methotrexate therapy. J Hand Surg Br 36(6): 490-497, 2011.
Chapter 37
Operative Reconstruction of Digital Polydactyly, Including the
Duplicated Thumb
Heather R. Harrison
Kevin J. Little
PREAXIAL POLYDACTYLY
The duplicate thumb was first described in 1645 by Digby, and its treatment has continued to evolve and be
improved since. The presence of a duplicate thumb usually represents an indication for surgical reconstruction
due to psychosocial, cosmetic, cultural, and functional concerns. The reported incidence varies greatly but is
most commonly reported as 1 per 3,000 live births (1). It is found equally in blacks and whites but is slightly more
common in Native Americans and Asians. It is categorized as a type of duplication as recommended by the
International Federation of Societies for Surgery of the Hand (IFSSH) and the American Society for Surgery of
the Hand (2,3,4).
The most commonly used classification for preaxial polydactyly was described by Wassel and has been used to
accurately describe the presentation of the duplicate thumb. This system defines the anatomic location of
duplication and is broken into seven categories, beginning distally with a bifid distal phalanx as type I. The odd
numbers represent incomplete duplications and the even represent complete duplications of bones. The Wassel
IV classification involves a single but widened metacarpal with duplication of the proximal and distal phalanges
and represents 43% of all cases. Wassel II involves a duplicated distal phalanx only and is the second most
common representing 15% of cases. Any triphalangeal thumb is classified as type VII (5) (Fig. 37-1).
A newer classification modification has been proposed by Zuidem and colleagues to better classify triphalangeal
thumbs as well as triplications and deviation. They also further described the position of the duplications using
m, u, and r to describe middle, ulnar, and radial locations, respectively (Fig. 37-2). None of the previously
described classification systems addresses the fact that neither of the thumbs in preaxial polydactyly is normal;
therefore, referring to it as a split thumb may be more accurate and better explain the treatment goals (6).
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FIGURE 37-1 Wassel classification of preaxial polydactyly. (Reproduced with permission from Wassel HD: The
results of surgery for polydactyly of the thumb. Clin Orthop 64: 179, 1969.)
FIGURE 37-2 Zuidem classification of preaxial polydactyly. (Reproduced with permission from Zuidem JM, et al.:
A classification system of radial polydactyly: inclusion of triphalangeal thumb and triplication. J Hand Surg Am
33(3): 374, 2008.)
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The overall surgical goals regardless of type are to ablate the hypoplastic component, combine structures from
both thumbs to create a stable metacarpophalangeal (MP) joint, align bony units, and centralize tendinous
structures to optimize motion while maintaining a healthy sensate pulp for pinch and prehensile activity (7,8,9).
The timing of surgical reconstruction is dictated by the progression of prehensile activity as well as safety. At 6
months of age, gross grasp and grip develop, while thumb and index finger pinch does not develop until 12 to 15
months of age. Established fine motor patterns develop between 2 and 3 years of age. Performing reconstruction
when the patient is 9 to 12 months of age decreases the risks associated with anesthesia while preceding
development of pinch, allowing this function to develop normally after the reconstruction. Allowing the hand to
grow during the first 9 to 12 months also allows for easier dissection of neurovascular and tendinous structures.
Contraindications to surgery are typically related to other underlying conditions. Conditions such as Holt-Oram,
Diamond-Blackfan, and Fanconi's anemia are more commonly seen with hypoplastic thumbs; however, they may
also be present with thumb duplication, especially if the duplicate thumb involves a triphalangeal component.
Hematologic indices as well as pediatric genetic consultation should be sought prior to proceeding with any
surgical intervention (3,7).
Duplication of the thumb usually occurs as a sporadic mutation; however, rarely, an autosomal dominant
inheritance pattern can be seen especially with type VII duplications, and genetic counseling should be offered to
these patients' parents. A complete blood count (CBC) and platelet count along with prothrombin time (PT)
should be assessed to rule out thrombocytopenia and coagulopathies (3,7).
It is important to explain early on to the parents that the child with a duplicate thumb will never have a completely
normal thumb after surgical reconstruction. This will help to avoid any misconceptions that may arise later.
Removal of the hypoplastic component and reconstruction of the dominant thumb will still leave the child with a
smaller and stiffer thumb. Long-term studies have shown that even after surgical reconstruction, interphalangeal
motion will be limited, averaging 0 to 30 degrees. The possibility of postoperative sequelae, such as joint laxity,
thumb size and appearance mismatch, and the zigzag deformity, should be discussed with the parents as well as
the 25% need for revision later as the child grows. These risks increase when the thumbs are crooked or
angulated preoperatively (10,11,12).
Preoperative physical and radiographic examinations both at presentation as a newborn and shortly prior to
planned intervention allow for refinement of the surgical plan, as well as developing a relationship with the family
and realistic expectations of outcomes. Examination of the digits will usually demonstrate that the more radial
component is hypoplastic and better suited for ablation; however, occasionally, the radial component is more
functional and will need to be salvaged (Fig. 37-3A,B). The flexor and extensor tendons are frequently displaced
radially and will need centralization. This should be examined and identified during preoperative examination.
Additionally, there are occasional connections between the extensor pollicis longus (EPL) and flexor pollicis
longus (FPL) tendons, known as pollex abductus, which will need to be identified and released to prevent
recurrent deformity (Fig. 37-4). The abductor pollicis brevis (APB) tendon often inserts on the radial thumb in
type IV duplications, which potentiates the angular deformity if not addressed at the time of surgery. Radiographs
most commonly in the Wassel IV presentation demonstrate a widened metacarpal head that requires
intraoperative reduction. Bony angulation of the metacarpals and phalanges should be evaluated to determine
the need for osteotomies. Collateral ligament stability should be assessed, as most commonly the radial
collateral ligament of the MP joint is unstable and will require reconstruction. Simple ablation of one of the
duplicate thumbs was previously attempted; however, this does not address the APB insertion, radial collateral
ligament reconstruction, or appropriate skeletal alignment of the remaining thumb and thus has not provided
satisfactory results (10,13,14).
Arteriography is not usually necessary for preoperative planning. The arterial pattern has been studied by
Kitayama, who found that more than 75% of the time there is a digital vessel to each component and 5% of the
time, there is only one single digital vessel to the ulnar component and none to the radial. In the rare case that
the radial component is determined to be more appropriate for reconstruction, this should be taken into
consideration (15).
In the patient with near-symmetrical type II or III duplication, we have a discussion with the family regarding the
outcomes of ablation and reconstruction versus modified Bilhaut-Cloquet as proposed by Baek et al. The
modified Bilhaut-Cloquet procedure has a higher rate of stiffness and decreased motion and frequently results in
nail deformities; however, it provides a more cosmetic result with a thumb more similar in width and appearance
to the contralateral side. Ablation and reconstruction should be selected if increased thumb motion and function
is preferred to a better cosmetic result (16,17,18).
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FIGURE 37-3 A,B: Clinical photograph and radiograph of a patient with the less common dominant radial
duplicated thumb and a hypoplastic ulnar duplicate thumb. (Images courtesy of Kevin J. Little, MD.)
FIGURE 37-4 Clinical photograph of the tagged pollex abductus connection between the EPL and FPL tendons.
(Photograph courtesy of Kevin J. Little, MD.)
The Bilhaut-Cloquet procedure described as a longitudinal osteotomy taking a central wedge resection of bone
and soft tissue and approximating the remaining components of the radial and ulnar digits is complicated by joint
stiffness, growth arrest, asymmetric growth, and nail bed deformities
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due to its intra-articular nature and physeal involvement (5,16,19) (Fig. 37-5). Naasan and Page (20) have
reported secondary deformities in 71% of thumbs reconstructed utilizing this technique. Remaining extra-articular
allowed Baek and colleagues to avoid growth arrest and nail bed deformities. The modified Bilhaut-Cloquet is
advocated in Wassel type II and III thumbs. In a small sample size of 7 patients, Baek and colleagues
demonstrated satisfactory functional and cosmetic results with preserved preoperative range of motion in type III,
improved range of motion in type II thumbs, and no cases of nail deformities or growth arrest (17,18).
FIGURE 37-5 The Bilhaut-Cloquet sharing procedure. (Reproduced with permission from Malliet M, et al.:
Results after surgical treatment of thumb duplication: a retrospective review of 33 thumbs. J Child Orthop 1(2):
136, 2007.)
FIGURE 37-6 Radially based zigzag incision.
Surgical Technique
Wassel Type IV Reconstruction with Excision of Hypoplastic Digit The surgery is performed under general
anesthesia in the supine position, with the upper extremity on a hand table. A tourniquet is placed high on the
arm and, after exsanguination, inflated to approximately 100 mm Hg above systolic pressure.
A zigzag incision is made beginning just distal to the carpometacarpal joint and continued to the base of the
radial hypoplastic thumb, around this in a racquet fashion and continued in a zigzag fashion along the radial
border to the level of the IP joint of the ulnar thumb. This incision should be constructed in a zigzag fashion as a
longitudinal scar will contract and can contribute to a postoperative angular deformity and thus should be
avoided (Fig. 37-6). The flaps are developed and can be
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tagged with suture to help in exposure. The initial dissection should identify and retain all structures to both
thumbs. Aberrant tendons along with neurovascular structures should be identified prior to any vascular
structures being ligated. EPL and FPL tendons are dissected proximal and commonly bifid at the level of the
bony duplication, ensuring that the pollex abductus is released. These are released at their insertions on the
radial thumb and tagged for later use.
Next, the APB muscle and tendon are identified from the thenar aspect to its insertion on the proximal phalanx of
the radial thumb taking care to not violate the underlying radial collateral ligament. The insertion is released and
tagged for later transfer to the ulnar thumb. The proximal phalanges may be completely duplicated and separate,
or there may be a cartilaginous connection, which should be transected longitudinally to the level of the MCP
joint (Fig. 37-7).
FIGURE 37-7 After the flaps are developed, the neurovascular bundles are identified and dissected out to their
respective digits; the APB tendon, usually attached radially, is detached and tagged and proximally retracted,
giving exposure to the MP joint.
FIGURE 37-8 With the thenar muscles retracted, a 10-mm-wide periosteal capsular sleeve is raised for later
reconstruction of the radial collateral ligament to the MP joint. The widened metacarpal head is now visible for
inspection and identification of dual facets.
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The radial collateral ligament is then dissected off of the proximal phalanx of the radial hypoplastic thumb along
with a strip of periosteum and the underlying joint capsule. This allows for later use to reconstruct the RCL and
advance it volarly to balance the thumb (Fig. 37-8). With the RCL identified and tagged, the underlying widened
metacarpal head can be examined (Fig. 37-9). If it is found to have 2 articular facets, the extra radial facet is
removed with either a no. 15 blade or no. 67 Beaver blade using the radial border of the anatomically aligned
ulnar proximal phalanx as a guide. If the metacarpal is found to be angulated in an ulnar direction, a radially
based closing wedge osteotomy is performed with a rongeur, keeping the ulnar cortex intact as a hinge. Bony
alignment and fixation is achieved with a 0.028-inch Kirschner wire passed retrograde through the distal phalanx
and proximal phalanx and into the metacarpal stabilizing the IP and MCP joints (Fig. 37-10). Intraoperative
fluoroscopy should be used to guide appropriate alignment of the joints as well as K-wire position. Rarely, an
osteotomy at the level of the proximal phalanx will be necessary to ensure that the IP and MCP joint surfaces are
perpendicular to the longitudinal axis of the bone.
The reconstructed radial collateral ligament of the MP joint is attached distally and volarly to recreate its normal
orientation using suture through the base of the proximal phalanx (Fig. 37-10). The previously tagged APB
tendon is then attached with suture to the periosteum at the base of the proximal phalanx on the radial aspect. At
this point, the EPL and FPL tendons need to be centralized along the longitudinal axis of the reconstructed
thumb. This is done by suturing the previously tagged aberrant tendons to the retained EPL and FPL insertions,
respectively, allowing for a more central pull actively. This helps prevent development of an angular deformity
with time. The skin flaps are then rotated into place and the zigzag incision is then closed with 6-0 absorbable
suture, trimming excess skin as necessary.
FIGURE 37-9 The combined reduction closing wedge osteotomy is illustrated.
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FIGURE 37-10 The reconstructed radial collateral ligament and advanced APB tendon, along with longitudinal K-
wire aligning the osteotomies. The flaps are turned and closed in a zigzag fashion to prevent longitudinal linear
contracture.
FIGURE 37-11 Clinical photograph of a patient with a Wassel type II deformity with near-equal sizes of radial and
ulnar duplicates. (Photograph courtesy of Kevin J. Little, MD.)
The K-wire is cut outside of the skin and bent. A sterile dressing is applied over the incision and the tourniquet
released before final application of the dressing to confirm vascularity. A long-arm mittentype cast is applied,
incorporating all of the digits, including the thumb to adequately protect the pin.
Reconstruction of Types I, II, and III Using a Modified Bilhaut-Cloquet Technique The surgery is again
performed under general anesthesia in the supine position, with the upper extremity on a hand table. A
tourniquet is placed high on the arm and, after exsanguination, inflated to approximately 100 mmHg above
systolic pressure (Fig. 37-11).
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Both nails are initially removed, and longitudinal incisions are made in each nail bed so that once combined they
will have a size similar to the contralateral thumb. The skin incision is then extended in a zigzag fashion
proximally to the level of the bony bifurcation. The thumbs are examined, and if there is a difference in the IP
range of motion, the thumb with greater motion is selected as the one to retain the articular portion of and a
portion of the distal part of the phalanx. The other thumb is then made into a fillet flap containing only a portion of
the phalanx distal to the physis to support the nail bed and proximal enough to maintain the collateral ligament
insertion site with the flap (Fig. 37-12A). The two distal phalanx portions do not need to be perfectly contoured to
match one another. The two distal phalanx portions are then secured with transverse K-wire fixation with each
piece rotated slightly outward in the axial plane allowing for the dorsal surface to be semicircular and provide a
normal-appearing nail bed.
The nail bed is then repaired with 8-0 nylon suture under tension to help prevent ridge formation in the nail. The
stability of the IP joint should then be tested, and if unstable, a longitudinal K-wire can be placed across the IP
joint from the tip to the thumb to provide extra stability during healing. One of the previously removed nails should
be trimmed and placed on the new nail bed and sutured in place to maintain the eponychial fold and help contour
the new nail bed.
For type III duplications, this process is modified by performing an osteotomy at the bifurcation site and excising
the extra portion of the proximal phalanx and the entire distal phalanx except the most distal portion of the
phalanx supporting the nail bed. A closing wedge osteotomy of the retained proximal phalanx should be
performed if there is a residual angular deformity of greater than 20 degrees (Fig. 37-12B). In this case, a
transarticular K-wire should be placed from the tip of the thumb proximally to maintain the alignment of the
osteotomy site. The skin flaps are then rotated into place, and the zigzag incision is then closed with 6-0
absorbable suture, trimming excess skin as necessary. The K-wire(s) is (are) cut outside of the skin and bent. A
sterile dressing is applied over the incision and the tourniquet released before final application of the dressing to
confirm vascularity. A long-arm mitten-type cast is applied, incorporating all of the digits, including the thumb
(14,21,22,23,24).
FIGURE 37-12 A,B: Modified Bilhaut-Cloquet procedure for Wassel type II and III polydactyly of the thumb.
(From Baek GH, Gong HS, Chung MS, et al.: Modified Bilhaut-Cloquet procedure for Wassel type-II and III
polydactyly of the thumb. J Bone Joint Surg Am 90(Suppl 2, Part 1): 74-86, 2008.)
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The patient is typically admitted overnight for pain control. If there are no postoperative problems, the patient is
seen at 4 weeks with cast removal and x-rays out of the cast. If there is good evidence of bony healing, the pin(s)
is (are) removed, and the patient is placed into a resting thumb spica splint for an additional 3 weeks full time
except for bathing and eating. During this time, initiation of active range of motion is performed. At the end of 6
weeks, the splint is usually reduced to nighttime and naptime wear, for an additional 6 months.
Continued growth of the thumb should be monitored with serial clinical and radiographic exam at least yearly to
identify and treat any future angular deformity if it should develop. During the postoperative time, the family
should again be reminded of the up to 25% need for revision surgery as the thumb grows. Again, the
reconstructed thumb will likely be smaller and stiffer than the contralateral normal thumb; however, the child
should be expected to have excellent prehensile function and satisfactory appearance of the thumb.
Complications
Despite strict adherence to reconstruction principles, tendon malalignment, violation of ligamentous
structures, or alterations in the bony architecture can lead to joint instability and/or eccentric tendon
dynamic force. Over time, these errors in reconstruction may result in joint angulation or zigzag deformity
(Fig. 37-13). This has classically been described as ulnar deviation at the MCP joint and radial deviation at
the IP joint. Reasons for the deformity include contracted scar tissue, abnormal insertion of flexor or
extensor tendons resulting in radial pull, and deficient radial thenar musculature (10,11,12). Studies have
found the deformity to present in upward of 33% of patients after reconstruction.
Treatment of this zigzag deformity requires restoration of parallel joint surfaces, restitution of joint stability,
realignment of tendons, and treatment of scar contracture (11). In order to restore bony alignment, extra-
articular closing wedge osteotomies may be necessary of the phalanx or metacarpal as indicated by the
location of the angular deformity. MCP deviation can typically be address by capsular reconstruction and
transferring the APB to the dorsoradial aspect of the proximal phalanx (Figs. 37-14 and 37-15). Reorienting
the pull of the FPL and EPL tendons will address the IP joint radial deviation (10,11). For contracted scar
tissue, Z-plasty surgery can be performed in addition to correction of underlying bone and soft-tissue
malalignment. Lee et al. proposed an algorithm to provide objective guidelines for decision making in
treating the zigzag deformity, and this is provided in Figure 37-16 (10).
FIGURE 37-13 Residual deformity at the MP and IP joint of the right thumb 8 years following Wassel IV
correction. (Photograph courtesy of Kevin J. Little, MD.)
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FIGURE 37-14 The proposed reconstruction of the zigzag deformity, with reconstruction of the radial
collateral ligament and reconstructive osteotomies to realign the bony units.
FIGURE 37-15 The postoperative correction.
Limited range of motion specifically at the IP joint is also common and averages less than 30 degrees of
flexion. Repeat joint releases have not been successful to improve motion. If pain develops, an arthrodesis
can be considered. Persistent deformity at the IP joint, despite corrective surgery, often is best treated with
interphalangeal joint arthrodesis or chondrodesis as this provides stability and will prevent future deformity.
Instability at the MP joint is typically the result of inadequate advancement of the periosteal capsular flap
and often needs revision if the angular deformity becomes significant. Care must be taken during the initial
reconstruction in developing this flap to prevent retaining any cartilage, which may later ossify and cause
bony prominence and worsen the instability. Reoperation can result in further joint stiffness and again if
symptomatic, arthrodesis, and chondrodesis can be done (10,25).
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FIGURE 37-16 Algorithm for surgical procedures for zigzag deformity. (Reproduced with permission from
Lee CC, Park HY, Yoon JO, et al.: Correction of Wassel type IV thumb duplication with zigzag deformity:
results of a new method of flexor pollicis longus tendon relocation. J Hand Surg Eur Vol 38(3): 275, 2013.)
FIGURE 37-17 Well-formed postaxial type A polydactyly. (Photograph courtesy of Kevin J. Little, MD.)
POSTAXIAL POLYDACTYLY
A duplicate digit on the ulnar border of the hand is referred to as postaxial polydactyly. Overall, the incidence in
blacks is estimated to be as high as 1 in 300 live births, whereas the incidence in Caucasians is estimated to be
1 in 3,000 live births. There is an autosomal dominant pattern of inheritance with incomplete penetration and
variable expressivity (1,26,27,28).
When postaxial polydactyly is present in Caucasians, it commonly has syndromic associations, particularly with
cardiac and renal malformations. The evaluating surgeon needs to be aware of these associations. When
postaxial polydactyly is seen associated with a genetic syndrome, it is usually inherited in an autosomal
recessive manner. Chromosomes 7, 13, and 19 have individually been identified as potential sites of mutation
responsible for postaxial polydactyly. Postaxial polydactyly is associated with trisomy 13, Ellis-van Creveld,
Laurence-Moon-Bardet-Biedl, and Meckel's syndromes. In general, polydactyly of the hand is more commonly
associated with other musculoskeletal abnormalities (i.e., polydactyly of toes) than other organ system
abnormalities (1,3,4,6,27,28,29,30).
Postaxial polydactyly has been classified by Temtamy and McKusick into a simple two-part scheme of
phenotypic expression (27). Type A postaxial polydactyly (Fig. 37-17) is defined as a fully developed extra digit,
whereas type B is a rudimentary digit. Type A and type B occur equally in whites; however, in those of African
descent, type B is more common (3).
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The indication to proceed with surgical intervention for postaxial polydactyly is predominantly psychosocial.
Patients with type A fully functioning and well-aligned extra digits do not have a significant medical indication for
ablation; however, psychosocial, cultural, and cosmetic concerns play an important role in surgical decision
making. Type B polydactyly excision, while technically more simple, is somewhat more controversial with regard
to deciding what technique to proceed with. Our preference is ablation of the rudimentary digit by elliptical
excision, identification and proximal ligation of the digital nerve, and primary closure in the operating theater. We
believe that the psychosocial complications of having a rudimentary stump after simple ligation are underreported
and, when combined with other frequent sequelae, such as painful neuroma, lead to an unacceptably high
dissatisfaction rate. Contraindications for surgical intervention are related to other underlying conditions and not
directly related to the duplicate digit.
For type B postaxial polydactyly, the decision must be made as to proceed with ligation versus excision. A
thorough discussion with the family weighing the pros and cons of the treatment choices should be had. Some
families may have a preference due to their personal prior experience of one option over the other, and this
should be taken into consideration. Advantages of ligation as a newborn include no need for anesthesia, cost-
effectiveness, and low risk of complications. Potential disadvantages include a risk of bleeding and infection,
symptomatic neuroma formation, and residual nubbin on the ulnar border of the hand, which may be cosmetically
displeasing. Additionally, in patients where a wide skin bridge is present between the vestigial finger and the
hand, suture ligation is contraindicated as there is an unacceptably high rate of partial ligation leading to venous
congestion, pain, and need for additional procedures. Advantages of elliptical excision include decreased risk of
neuroma formation and bleeding due to formal nerve transection and vascular coagulation. Potential
disadvantages are the need for general anesthesia as well as the delay in removal to allow for the safety of
general anesthesia (31,32).
For type A postaxial polydactyly, the decision must also be made with the family taking into consideration cultural
and religious preferences. Preoperative counseling should include discussion of the slight risk of an abduction
deformity of the remaining small finger. Typically, this does not occur as long as reconstruction principles are
followed strictly. The quality of the digit preoperatively will directly influence the outcome, and families should
also be counseled in regard to this if the digit to be preserved is hypoplastic or stiff.
Surgical Technique
Type B Postaxial Polydactyly The surgery is performed under general anesthesia in the supine position, with
the upper extremity on a hand table. An Esmarch bandage is used to exsanguinate the extremity and is used as
a midforearm tourniquet, or an appropriately sized, nonsterile, brachial, or antebrachial tourniquet can be used.
An elliptical incision is made around the rudimentary digit. The neurovascular pedicle is identified with blunt
dissection. The artery is coagulated with electrocautery, and the nerve is cut under traction and allowed to
retract back into the hand. The skin is closed with 5-0 chromic suture and a soft dressing is applied (32,33,34).
Type A Postaxial Polydactyly The surgical technique is nearly identical to that for Wassel type IV ablation and
reconstruction (3,35,36). The surgery is performed under general anesthesia in the supine position, with the
upper extremity on a hand table. A tourniquet is placed high on the arm and, after exsanguination, inflated to
approximately 100 mmHg above systolic pressure.
A zigzag incision is made beginning just distal to the carpometacarpal joint and continued to the base of the ulnar
duplicated digit, around this in a racquet fashion (Fig. 37-18A). The volar and dorsal flaps are developed and can
be tagged with suture to help in exposure. The extensor mechanism is often found to be duplicated to the extra
digit, and this should be detached distally from its insertion and tagged for use later. The abductor digiti quinti
(ADQ) is typically found to insert volarly into the more ulnar digit and should be traced distally to its insertion
point and tagged for transfer later to the more radial digit (Fig. 37-18B).
The ulnar collateral ligament (UCL) is then dissected off of the proximal phalanx of the ulnar digit along with a
strip of periosteum and the underlying joint capsule. This allows for later use to reconstruct the UCL and
advance it volarly to balance the ulnar digit. With the UCL identified and tagged, the underlying widened
metacarpal head can be examined (Fig. 37-18C). If it is found to have 2 articular facets, the extra ulnar facet is
removed with either a no. 15 blade or no. 67 Beaver blade using the ulnar border of the anatomically aligned
proximal phalanx of the retained as a guide. Intraoperative fluoroscopy should be used to guide appropriate
alignment of the joints.
P.506
FIGURE 37-18 A: Clinical photograph of the hand, depicting the surgical incision. Superficial dissection
demonstrates a bifid extensor mechanism. B: Volar dissection demonstrates attachment of the ADQ to the more
ulnar small finger. C: Arthrotomy of the MCP joint reveals a bifacet metacarpal head (arrow), typical of type A
postaxial polydactyly. D: After the digit is removed and chondroplasty of the metacarpal head completed (arrow),
the UCL is reconstructed and advanced to its anatomic insertion on the proximal phalanx. E: The ADQ is
reapproximated, and a stabilizing smooth pin is placed for postoperative protection. F: Final appearance of the
hand after wound closure. (From Waters P: Pediatric hand and upper limb surgery: a practical guide.
Philadelphia, PA: Lippincott Williams and Wilkins, 2012.)
P.507
The reconstructed UCL of the MP joint is attached distally into the volar plate of the retained digit to recreate its
normal orientation using suture. The previously tagged ADQ tendon is then attached with suture to the
periosteum at the base of the proximal phalanx and extensor mechanism. At this point, the flexor and extensor
tendons should be centralized by suturing the previously tagged aberrant tendons to the retained extensor and
flexor tendons, respectively, allowing for a more central pull actively. This helps prevent development of an
angular deformity with time. The skin flaps are then rotated into place, and the zigzag incision is then closed with
6-0 absorbable suture, trimming excess skin as necessary.
If the MCP joint is unstable to examination, a longitudinal smooth 0.028-K-wire can be placed for additional
temporary stabilization (Fig. 37-18D-F). The K-wire is cut outside of the skin and bent. A sterile dressing is
applied over the incision, and the tourniquet released before final application of the dressing to confirm
vascularity. A long-arm mitten-type cast is applied, incorporating all of the digits.
For type A excision, the patient is typically admitted overnight for pain control. If there are no postoperative
problems, the patient is seen at 3 weeks with cast removal and x-rays out of the cast. If there is good evidence of
bony healing, the pin(s) is (are) removed, and the patient is placed into a resting thumb spica splint for an
additional 3 weeks full time except for bathing and eating. During this time, initiation of active range of motion is
performed. At the end of 6 weeks, the splint is usually reduced to nighttime and naptime wear, for an additional 6
months.
Continued growth of the hand should be monitored with clinical and radiographic exam to identify and treat any
future angular deformity; however, this is rare.
For type B excision, the patient is discharged home in the soft dressing, which should be maintained for 1 week.
The patient is seen back in the clinic for a wound check at that time, and then no further follow-up is needed
unless there are problems or concerns.
Complications
There are very rarely complications associated with type B excision. As described above, the complications
are associated with the treatment chosen and for simple ligation potentially include a risk of bleeding and
infection, symptomatic neuroma formation, and residual nubbin on the ulnar border of the hand, which may
be cosmetically displeasing (Fig. 37-19). With type A excision, there is a slight risk of an abduction deformity
of the remaining small finger, and the quality of the digit preoperatively will directly influence the outcome if
the digit to be preserved is hypoplastic or stiff (3,35).
FIGURE 37-19 Residual nubbin after suture ligation performed by neonatologist. Surgical elliptical incision
performed to revise outgrowth. (Photograph courtesy of Kevin J. Little, MD.)
P.508
CONCLUSION
The successful treatment of the duplicate finger or thumb requires adherence to established principles and
recognition of detail to all aspects of the reconstruction. Preoperative discussion with the family is important
to outline appropriate goals and outcomes. The successful procedure includes judicious use of skin
incisions, reattachment of the thenar or hypothenar muscles, reconstruction of the MP joint, osteotomies of
the metacarpal and proximal phalanx as needed to align bony units perpendicular to the longitudinal axis,
and frequently redirection of tendinous structures. Although the reconstructed thumb may be somewhat
smaller and stiffer than the contralateral, function should be satisfactory, and the infant should develop
excellent prehensile activity.
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Techniques in Orthopaedic Surgery The Hand 3rd Edition 3nbsped

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Editors

Peter J. Evans MD, PhD

Ngozi Mogekwu Akabudike, MD

Blaine Todd Bafus, MD

Colleen Davis, OTR/L

Peter J. Evans, MD, PhD

Beatrice L. Grasu, BS, MD

Donald Lalonde, BSc, MSc, MD, FRCSC

Susan E. Mackinnon, MD, FRCS(C), FACS

Kenneth Robert Means Jr, MD

Loukia K. Papatheodorou, MD, PhD

Ebrahim Paryavi, MD, PhD

Allan E. Peljovich, MD, MPH

David E. Ruchelsman, MD, FAAOS

Julie Balch Samora, MD, PhD, MPH

Rebecca J. Saunders, PT, CHT

Keith A. Segalman, MD, FACS

William H. Seitz Jr, MD

Beth Paterson Smith, PhD

Dean G. Sotereanos, MD, PhD

Catherine Szado, OT/L, CHT

Carley B. Vuillermin, MBBS, FRACS

Bradon J. Wilhelmi, MD, FACS

Jonathan Amer Zelken, MD

Acquisitions Editor: Brian Brown

To my family, colleagues, students, and patients.

To Caroline, my children, colleagues, trainees, and patients.

Video 10-1 Acute trauma 1.

Video 10-2 Acute trauma 2.

Video 10-3 Acute trauma 3.

Video 10-4 Acute trauma 4.

Video 10-5 Acute trauma 5.

Video 10-6 Acute trauma 6.

Video 10-7 Posttraumatic reconstruction 1.

Video 10-8 Posttraumatic reconstruction 2.

Video 10-9 Burn and congenital hand reconstruction 1.

Video 10-10A Burn and congenital hand reconstruction 2.

Video 10-10B Burn and congenital hand reconstruction 3.

Video 10-10C Burn and congenital hand reconstruction 4.

Video 10-10D Burn and congenital hand reconstruction 5.

Video 10-10E Burn and congenital hand reconstruction 6.

Video 10-11A Surgical technique 1.

Video 10-11B Surgical technique 2.

Video 10-11C Surgical technique 3.

Video 10-11D Surgical technique 4.

Video 10-11E Surgical technique 5.

Video 10-11F Surgical technique 6.

Video 10-11G Surgical technique 7.

Video 10-11I Surgical technique 9.

Video 10-11J Surgical technique 10.

Video 10-11K Surgical technique 11.

Video 10-11L Surgical technique 12.

Video 10-11M Surgical technique 13.

Video 10-11N Surgical technique 14.

Video 10-11O Surgical technique 15.

Video 10-11P Surgical technique 16.

Video 10-12 Surgical technique 17.

Video 10-13A Surgical technique 18.

Video 10-13B Surgical technique 19.

Video 10-14 Surgical technique 20.

Video 10-15A Postopertative management 1.

Video 10-15B Postopertative management 2.

Video 10-16 Results.