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https://archive.org/details/practicalhandsur0000unse
Practical
Hand
Surgery
 From the Annual Georgetown Hand Symposium
Sponsored by
National Hand Research and Rehabilitation Fund, Inc.
and
American Association for Hand Surgery
 Practical
Hand
Surgery
Edited by
Norman J. Cowen, M.D.
Hand Surgeon;
President and Chairman, Board of Directors of the
National Hand Research and Rehabilitation Fund, Inc.;
Consultant, National Upper Extremity Rehabilitation Clinic,
Washington, D.C.

Published by

Sy Sta Seville
MEDICAL ED BOOKS

Distributed by
®

ub YEAR BOOK
Ln MEDICAL PUBLISHERS
CHICAGO « LONDON
 A HOME STUDY TEXTBOOK PROGRAM
This book approved for
Category | Accreditation
The seal that Wuarante es y,
Ou

ese, - cation
7 Conrinuind Ed

As an organization accredited for continuing medical educa-

tion, the American Association for Hand Surgery designates
that this continuing medical education activity meets the
criteria for CATEGORY 1 FOR THE PHYSICIAN’S
RECOGNITION AWARD of the American Medical Associa-
tion provided it is used and completed according to the
instructions.

To obtain the final examination, see colored insert at inside back cover.
i

© 1980 by Symposia Specialists, Inc.

All rights reserved. No part of this publication
may be reproduced or transmitted in any form or
by any means, electronic or mechanical, including
photocopy, recording or any information storage
and retrieval system, without permission in
writing from the publisher.

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Distributed by
Year Book Medical Publishers
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Library of Congress Catalog Card Number 80-52651

International Standard Book Number 0-8151-1871-6

Printed in the United States of America

 This book is dedicated to Dr. Robert E. Carroll
and Dr. James Hunter, who taught me the science
and the art of hand surgery.
 Acknowledgments

I would like to thank all the faculty of the Annual

Georgetown Hand Symposia of past years for their help and
this
inspiration which has culminated in the production of
book. I wish to thank Ms. Evelyn Mackin for her very special
help in preparing some of the manuscripts. Finally, I wish to
thank my wife, Dr. Sheila Cowen, for her help in reviewing and
proofing the manuscripts.
N.J.C.
 Contents

Preface Xili

INTRODUCTORY HAND SURGERY

Evaluation of the Injured Hand: Preoperative

Preparation.
John S. Gould, WED.
Division of Orthopaedic Surgery
Univetsity of Alabama Medical Center
Birmingham

Predictors of a Stormy Postoperative Course 11

J. Leonard Goldner, M.D.
Division of Orthopaedic Surgery
Duke University Medical Center
Durham, N.C.

Postoperative Management of Tenolysis 2d

Evelyn J. Mackin, L.P.T.
Hand Rehabilitation Center, Ltd.
Philadelphia, Pa.

SOFT TISSUE INJURIES OF THE HAND

Vincula in No-Man’s Land ; 39

Naoyuki Ochiai, M.D., Takeshi Moist “MD.
Robert J. Merklin, MD., James M. Hunter, M. D.
and Glenn A. Mackin, Pet
Thomas Jefferson University
Philadelphia, Pa.

The Intact Sublimis . 53

Edward A. Nalebuff, M.D.
Division of Orthopedic Surgery
Harvard Medical School
Boston, Mass.

vii
 CONTENTS
vill

69
Extensor Tendon Injuries
Grady S. Clinkscales, Jr., M.D.
Division of Orthopaedic Surgery
Grady Memorial Hospital
Atlanta, Ga.

oh
Penetrating Wounds: Initial Care and Management
Joseph A, Arminio, M.D.
Private Practice in Surgery
Wilmington, Del.

93
Management of Flaps in Hand Surgery
Ivens C. LeFlore, M.D.
Private Practice in Hand Surgery
Washington, D.C.

Replantation and Revascularization mL

William B. Kleinman, M.D.
Department of Surgery
St. Vincent Hospital and Health Care Center
Indianapolis, Ind.

Sensibility Evaluation oat Ut

Evelyn J. Mackin, L.P.T.
Hand Rehabilitation Center, Ltd.
Philadelphia, Pa.

Sensibility Reeducation sl 23
Evelyn J. Mackin, L.P.T.
Hand Rehabilitation Center, Ltd.
Philadelphia, Pa.

Management of Edema m3)

Shellye Bittinger, O.T.R.
Occupational Therapy Department
North Carolina Memorial Hospital
Chapel Hill

PANEL: TRAUMATIC HAND PROBLEMS

Discussion: Traumatic Hand Problems . 143

Moderator: J. Leonard Goldner, M.D.

CONGENITAL HAND PROBLEMS

Radial Club Hand eeLOl

William H. Bowers, M.D.
CONTENTS

Division of Orthopaedic Surgery -

University of North Carolina School of Medicine
Chapel Hill

Surgical Management of the Hypoplastic Hand wh 73

Norman J. Cowen, M.D.
National Hand Research and Rehabilitation Fund, Inc.
Washington, D.C.

Polydactyly — A Ten-Year Experience at Duke Medical Center . 207

MitchelA. Lipton, M.D. and J. Leonard Goldner, M.D.
Private Practice,
Phoenix, Ariz. and
Division of Orthopaedic Surgery
Duke University Medical Center
Durham, N.C.
4

COMMON OFFICE PROBLEMS

Carpal Tunnel Syndrome p21

Macy G. Hall, M.D.
Division of Plastic and Reconstructive Surgery
Howard University
Washington, D.C.

Compression Syndromes el}:

Edward A. Rankin, M.D.
Private Practice in Surgery
Washington, D.C.

Trigger Fingers and de Quervain Disease : » OBI

B. Scott Teunis, M.D. and Norman J. Cowen, aEDe
Private Practice in Hand Surgery
McLean, Va.; and
National Hand Research and Rehabilitation Fund, Inc.
Washington, D.C.

The Sensory Neuroma — [ts Prevention m2)

William H. Bowers, M.D.
Division of Orthopaedic Surgery
University of North Carolina School of Medicine
Chapel Hill

Treatment of Painful Amputation Stumps . 241

John S. Gould, M.D.
Division of Orthopaedic Surgery
University of Alabama Medical Center
Birmingham
 CONTENTS
x

. 249
Soft Tissue Tumors of the Hand
Avrum I. Froimson, M.D.
Division of Orthopaedic Surgery
Case Western Reserve University
Cleveland, Ohio

Outpatient Hand Surgery: The Hand Surgery Center:

A New Concept ae Ba e fa treet See 2261
Kim L. Lie, M.D.
The Hand Surgery Center
Warren, Mich.

BONE AND JOINT PROBLEMS

Displaced and Nondisplaced Fractures in the Hand 7269

Grady S. Clinkscales, Jr., M.D.
Division of Orthopaedic Surgery
Grady Memorial Hospital
Atlanta, Ga.

Articular Fractures and Fracture Dislocations Mer Th!

Joseph E. Imbriglia, M.D.
Division of Orthopedic Surgery
University of Pittsburgh School of Medicine
Pittsburgh, Pa.

Dislocations of the Small Joints of the Hands —

Simple and Complex woes
David C. Bush, M.D.
Division of Orthopaedic Surgery
Geisinger Medical Center
Danville, Pa.

Capsular Injuries of the Proximal Interphalangeal Joint . 305

William H. Bowers, M.D.
Division of Orthopaedic Surgery
University of North Carolina School of Medicine
Chapel Hill

Arthritis of the Basal Thumb Joints: A Technique

for Implant Arthroplasty ey
James W. Strickland, M.D.
Division of Orthopaedic Surgery
Indiana University Medical School
Indianapolis, Ind.
CONTENTS
Xl

RHEUMATOID ARTHRITIS

Surgical Treatment of the Swan-Neck Deformity

moRbeumatom Arthritis- 5... 4... . 2.0 fool
Edward A. Nalebuff, M.D. and Lewis H. Millender, M.D.
Division of Orthopedic Surgery
Harvard Medical School
Boston, Mass.

Thumb Problems in Rheumatoid Arthritis 5 ee

John S. Gould, M.D.
Division of Orthopaedic Surgery
University of Alabama Medical Cente:
Birmingham

Dorsal Swellings of the Wrist: Diagnosis and Treatment . 363

F. William Bora, Jr., M.D. and Robert R. Kaneda, D.O.
Department of Orthopedics
Hospital of the University of Philadelphia
Philadelphia, Pa.

Wrist Problems. <1913

Bruce Butler, Jr., M.D.
Private Practice in Hand Surgery
Alexandria, Va.

PANEL: GENERAL HAND PROBLEMS

Discussion: General Hand Problems £319;

Moderator: Grady S. Clinkscales, M.D.

ANNUAL WASHINGTON REVIEW COURSE

IN HAND SURGERY

Upper Extremity Prosthetics: Prescription Writing,

Sources of Power, and Harnessing 382
Charles H. Epps, Jr., M.D.
Division of Orthopaedic Surgery
Howard University Medical Center
Washington, D.C.

The Treatment of Nerve Injuries 25

F. William Bora, Jr., M.D.
Department of Orthopedics
Hospital of the University of Philadelphia
Philadelphia, Pa.
 CONTENTS
xl

Spastic and Paralytic Hand Problems . 409

Norman J. Cowen, M.D.
National Hand Research and Rehabilitation Fund, Inc.
Washington, D.C.

Two-Stage Tendon Reconstruction Using Gliding

Tendon Implants . 429
James M. Hunter, M.D.
Division of Orthopedic Surgery
Jefferson Medical College
Philadelphia, Pa.

Hand Therapy Program for Staged Tendon Grafting Using

Gliding Tendon Implant (Hunter Design) . 459
Evelyn J. Mackin, L.P.T.
Hand Rehabilitation Center, Ltd.
Philadelphia, Pa.

Wrist Arthrography . 481

Robert L. Hamm, M.D.
Department of Radiology
Providence Hospital
Washington, D.C.

Infections of the Hand . . 493

James W. Strickland, M.D.
Division of Orthopaedic Surgery
Indiana University Medical School
Indianapolis, Ind.

Carroll Technique of Small-Joint Arthrodesis Slt

Joseph E. Imbriglia, M.D.
Division of Orthopedic Surgery
University of Pittsburgh School of Medicine
Pittsburgh, Pa.

Medicolegal Update 5 BPA!

J. Joseph Danyo, M.D.
Division of Orthopedics
York Hospital
York, Pa.

Answers to Self-Evaluation Quizzes 27

 Preface

Despite the recent appearance of a myriad of books on

various aspects of hand surgery, no single text. has appeared
which can serve as a basic “first book” to introduce the reader
to this relatively new specialty. This volume is designed to
answer this need. It deals with the more important aspects of
hand surgery in a very readable manner without going into
excessive detail. The authors have stressed basic principles and
expanded their topic in proportion to its importance. More
advancéd material is contained in the two panel discussions and
in the section entitled ““Annual Washington Review Course in
Hand Surgery.” The anatomy is discussed in individual papers as
needed. A few papers have been included to acquaint the reader
with interesting recent developments and some areas under very
active investigation.
As a basic text, it should provide sufficient general
knowledge of hand surgery for medical students and residents
who rotate through orthopedic and plastic surgical services. For
orthopedic, plastic, general surgery and emergency room res-
idents, it can be their “first book”’ to introduce the subject and
to organize their thinking. As interest and time allow, these
residents can read the classical references listed at the end of
several papers, as well as more detailed texts. Residents
preparing for board examinations should find the section on the
Review Course very helpful.
Because it includes current trends and recent developments
as well as basic principles, the text should be extremely useful
to surgeons doing a modest amount of hand surgery who have
had little recent formal training in this subspecialty.
Several papers are written with the occupational and
physical therapist in mind. In general, the text should serve to
make them familiar with the general principles and goals of the
surgery which is performed on their patients. It should help
them to be able to discuss various aspects of the surgery with
these patients and thus to allay unnecessary fear, to give

Rill
xiv PREFACE

encouragement and to reinforce the instructions of the physi-

nced
cian. By understanding the goals of surgery, the experie
may be able to recogni ze a patient with
hand therapist
unrealistic expecta tions or one who does not underst and the
risks, complications or uncerta inties of surgery and bring this to
the attention of the patient’ s physici an.
The general content and its manner of presentation should
also make the book of value to emergency room personnel,
operating room nurses and technicians, occupational and public
health nurses, insurance adjusters, compensation commissioners
and lawyers, and any other persons who have some contact with
patients having hand problems. For this group of people, it
should provide an understanding of the amount of preparation
and care required not only by the surgeon but also by the
patient himself in order to attain a good result.
The book has evolved from the Annual Georgetown Hand
Symposium, which began in 1973. I have had the duty and
honor of being the organizer and program director of this
symposium since its inception. The book also serves as a basic
text for those attending the symposium.

THE EDITOR
Introductory Hand Surgery
 Evaluation of the Injured Hand:
Preoperative Preparation
John S. Gould, M.D.

Objectives
1. To provide guidelines for the appropriate evaluation of
hand injuries in the emergency department.
2. To discuss the basic elements of history taking and the
rationale for obtaining this information from the
patient with an injured hand.
3. To discuss the pertinent points of the physical examina-
tion of the injured hand and the rationale for the exam.
4. To discuss the types of injuries that occur, and to
emphasize those which require urgent treatment and
those which appear innocuous, but are severe.
5. To discuss immediate emergency department manage-
ment of the injured patient, preoperative preparation
and responsibilities of informing support personnel; and
to discourage probing of wounds in a nonoptional
environment.

A most important initial step in management of the patient

with an injured hand is evaluation of the injury in the
emergency department. It is incumbent upon the examiner to
obtain essential information which will provide guidelines for
surgical management initially and for subsequent reconstruc-
tion. It is critical that the physician obtain a full history of the
circumstances of the injury and basic fundamental information
concerning the patient’s medical history and social circum-
part is
stances. A thorough physical examination of the injured
The deter-
‘particularly helpful while the patient is responsive.

dic Surgery;
John S. Gould, M.D., Associate Professor of Orthopae
of Hand Surgery, Universi ty of Alabama Medical Center,
Chief, Section
Birmingham.
4 J. S. GOULD

mination of the urgency for surgical management is also an

essential step. This implies an evaluation not only of the degree
of contamination and the age of the wound, but also particu-
larly the vascularity of the injured part. The time elapsed since
the injury occurred should be determined in order to assess the
urgency of the situation, as well as subsequent management in
the operating room. Replantation of an amputated member is
feasible up to 6 hours after amputation when the amputated
part contains muscle; with cooling to 4C, this time may be
prolonged to about 12 hours. When muscle is not involved,
replantation can be carried out at 12 hours after injury or even
later. In fact, experimental studies have determined that with
proper cooling, revascularization and replantation can be carried
out up to 36 hours later. The environment in which the injury
occurred should also be determined. For instance, a scalpel
wound in the operating room would be the ideal type of injury,
allowing immediate repair of all injured structures and primary
closure. On the other hand, if the patient being operated had
known hepatitis or syphilis, the problem would be complicated.
Injuries occurring to garbage collectors on their route or to
workers in a chicken processing plant are notorious for
complications. Butchers or housewives who sustain injuries
while cutting raw meat are felt to have grossly contaminated
wounds. Injuries occurring in a lumber mill or from a cotton
picker are often of the ripping and tearing type, with their own
special management problems. A laceration occurring in a river
or in the ocean may be complicated by rare and unusual
organisms. Injuries occurring in the home may or may not
provide unusual sources of contamination.

Type of Injury

Various types of injuries to the hand may occur; some

require only simple management and others cause such exten-
sive damage that the surgeon must be aware of the type of
injury to provide adequate treatment. Types of injuries include
clean or ragged lacerations, local or diffuse crushing injuries,
and complete or incomplete amputations. When a diffuse crush
occurs, reconstruction will be complicated, requiring grafting of
blood vessels, tendons, nerves and bone, as well as skin.
EVALUATION OF INJURED HAND 5

Avulsion injuries, particularly ring avulsions, create damage to

blood vessels and nerves which is often irreparable. Even
vascular replantation may not be able to retrieve injuries of this
type, although the advent of vein grafting has made it possible
to provide survival and, on some occasions, reasonable function.
Penetrating wounds have to be differentiated between high- and
low-velocity types. The wound produced by a standard low-
velocity missile at close range may well qualify as a high-
velocity injury. When this occurs, damage is usually far more
extensive than the local wound. Jet gun injuries with various
hydrocarbons and other fat solvents, grease and hot plastic
cause initially innocuous-appearing wounds, but the knowledge
that the injury was inflicted by a jet gun alerts the surgeon to
extensive damage requiring open management and frequent
redebridement. Burns vary from surface injuries in the thermal
burn to extensive involvement in the electrical injury. Cold
injuries must be thoroughly evaluated and managed, as is the
case in a variety of envenomizations. Bites range from innocu-
ous to lethal, although the initial injury may appear relatively
benign. Awareness of the various toxins inflicted in these
injuries is essential for appropriate management.

Social History

The patient’s age is an important factor, as is his general

health. Young, healthy individuals may be able to tolerate
extensive reconstructive procedures as well as extensive early
management, including replantation. Older patients with a
history of diabetes or other forms of vascular impairment are
often poor candidates for vascular reconstruction. Patients with
bleeding tendencies are poor candidates for anticoagulation.
The patient’s educational level and occupation also require
consideration. For a manual laborer, amputation of a digit may
be considered a ‘‘badge of courage,” and replantation may
require too extensive a loss of work time to be feasible. In
contrast, the loss of a thumb or hand in such an individual may
and his
destroy his ability to provide a livelihood for himself
family. In the case of a musician, for instance, for whom
a more extensive attempt
preservation of the digits is essential,
may be made to save a part.
 J. S. GOULD
6

Physical Examination

The examining physician should thoroughly evaluate each

anatomic structure of the hand. Crush injuries which appear to
have caused only a skin laceration may be retrievable with
revascularization, but if only the skin is sutured and the digit is
not properly evaluated, the digit may be lost. Evaluation
includes more than just examination of the skin and the
appearance on routine x-ray films of the injured part. Not only
must the skin be evaluated for its vascularity, but thorough
examination should also be done for the extensor and flexor
tendon mechanisms, the nerves, arteries, bones, joints and
ligaments. Both flexor and extensor mechanisms need to be
tested for individual functions. Each tendon function should be
carefully evaluated, and the surgeon should avoid the error of
being impressed by substitution manuevers. To test an indi-
vidual muscle, the part is placed in a position that its muscle
tendon unit controls and the patient is asked to maintain that
position against resistance. The examiner’s other hand then
palpates the activated tendon or muscle unit. If this function
cannot be determined, then one must assume that the part has
been injured. In patients who do not respond to an attempt to
test these functions, the digital cascade and stance is helpful in
diagnosing a lacerated tendon. The tenodesis effect, achieved by
flexing and extending the metacarpophalangeal joint or the
wrist, will help in determining whether the tendon is intact.
Both the sensory and motor nerves supplying an area need
to be tested. A discrete examination is carried out, including the
test for two-point discrimination. A patient may complain of
decreased or lost feeling in an area and may have two-point
discrimination or discrete sharp and dull discrimination, simply
indicating a contused nerve or mild neurapraxia. The findings
here are particularly helpful when examining a contused nerve.
If there is no evidence of sensibility in that nerve, the surgeon
should consider an epineurotomy, at least. If axonotmesis has
occurred, then a repair should be carried out. One must also be
aware of anomalous innervations and test autonomous areas. If
there is a question, a nerve block can be carried out on the
nerve that may be providing overlap.
EVALUATION OF INJURED HAND a

A detailed muscle examination is also critical to determine

motor function and, again, one should be aware of anomalous
innervation as well as partial lesions.
In assessing the status of the circulation, several tests are
helpful. These include the color of the part, capillary refill,
turgor of the pulp, use of the Doppler apparatus and skin
temperature. In our clinic, all of these modalities are utilized to
determine vascularity. If vascularity is absent, surgery becomes
urgent.
The bone is examined both clinically and with x-rays.
Tenderness may indicate a nondisplaced fracture, which may
not be apparent on x-ray film. Epiphyseal injuries may be
determined by palpating the specific area, with a strong
suspicion when the epiphyseal plate area is tender. Joints are
tested by palpating each to determine tenderness, by range of
motion and by stability to stress. A Xylocaine injection into the
joint may be helpful to determine instability. Stress films may
be taken to support the suspicion of an unstable joint.

Emergency Department Duties

In addition to the history and physical examination, the

emergency department physician must obtain basic laboratory
studies, including the blood count, urine analysis, type and
cross match, and clotting time or partial thromboplastin time.
An x-ray film which adequately visualizes the part involved
should be taken in both the AP and lateral projections, and
special views may be needed. When a part has been amputated,
both the remaining member and the amputated part should be
x-rayed. Following an adequate history, tetanus toxoid or
human tetanus antitoxin may be needed. With open injuries, a
broad-spectrum antibiotic may be administered intravenously,
and with certain envenomizations, antivenoms may be needed.
The patient may be given appropriate analgesics and, following
basic cleansing of the wound in an organic iodine solution, a
simple organic iodine dressing should be applied. Appropriate
ancillary help and the operating room personnel should be
informed of the requirements for any surgical procedure. It is
always helpful to inform the anesthesiologist as well, so that
appropriate anesthesia is given for the procedure. The probing
 J. S. GOULD
8

strongly
of open wounds in the emergency department is
The informa tion is usually unrelia ble and the
condemned.
maneuver may be dangero us to the underly ing and someti mes
precarious anatomy. Probing can also introduce bacteria into
the wound. Blood vessels should not be clamped; bleeding
should be controlled with simple pressure. The physical
examination should be considered the most reliable method of
evaluation. The wound can then be totally explored in the
operating room under proper conditions.

Conclusion

Initial evaluation of the injured hand requires the basic

fundamentals of good history taking and adequate physical
examination for the injured extremity. The examiner must be
expert and thorough in the examination. He should determine
the urgency of a surgical procedure and provide initial appropri-
ate emergency care to the injured part, as well as systemically.
The operating room staff and other individuals involved should
be fully informed of the type of injury, the general status of the
patient and the requirements for appropriate surgical manage-
ment. ‘
Self-Evaluation Quiz

1. An adequate history from a patient with an injured hand

includes:
a) Environment in which the injury occurred
b) Age of the wound
c) Type of injury
d) Patient’s age and occupation
e) Patient’s general health
f) All of the above
2. Physical examination of the injured hand:
a) Is an essential step in the emergency department
b) Should be delayed until the patient is anesthetized
c) Is superfluous until the operating room
d) Requires x-rays and skin evaluation only
3. Replantation of a severed digit, including the thumb, is
never feasible after six hours.
a) True
b) False
EVALUATION OF INJURED HAND 9

4. Diffuse crushing injuries may require grafting of:

a) Blood vessels
b) Tendons
c) Nerve
d) Skin
e) Bone
f) All of the above
5. Jet-gun injuries appear innocuous; therefore, which of the
following statements is true?
a) ‘Tetanus toxoid and a local dressing is sufficient
b) They are serious and require I & D in the emergency
room
c) They are serious, but of no urgency
d) Treatment is urgent and should be done in the operating
room
6. In this day and age, all amputated parts should be
replanted:
a) True
b) False
7. The surgeon in the emergency department should inform
the following personnel about the patient’s operative
requirements:
a) Assisting surgeons
b) Anesthesiologist
c) Operating room personnel
d) Patient and his family
e) All of the above

Answers on page 527.

46. Goo es Ve 2 a :
yeni Ses
magus
<cmptrs gle ae om
 Predictors of a Stormy
Postoperative Course
J. Leonard Goldner, M.D.

Objectives
The surgeon should attempt to obtain information
preoperatively that will aid in eliminating postoperative
vasospasm or diminished blood flow. Intraoperative pro-
cedures should avoid nerve irritation and diminish compart-
ment pressure by releasing critical layers of fascia. Postoper-
ative dressings should not cause pressure and postoperative
pain should be investigated and relieved.

Introduction

Complex problems arise during the course of emergency and

elective hand conditions. Complications associated with epi-
sodes of acute trauma involving the hand are not always
avoidable. This is true also for elective operative procedures.
However, certain factors, if considered, will diminish the
severity of unavoidable complications and possibly even prevent
them from occurring. Planning an elective operation should
include attempts at recognizing the patient’s individual charac-
teristics related to connective tissue, the tendency for vasopasm
and any anatomic anomalies of certain tissue complexes, as well
as constant awareness of developing complex complications.
Once injury has occurred, we as physicians and surgeons
must concentrate on avoiding complications that might occur
after the major accident.

J. Leonard Goldner, M.D., James B. Duke Professor and Chairman,

Division of Orthopaedic Surgery, Duke University Medical Center,
Durham, N.C.

al
 J. L. GOLDNER
12

Classifications of Complex Tissue Changes

y categorized
Changes in organ and tissue systems are usuall
tendons and muscles,
as those noted in skin, vascular structures,
and combinations of
joints, bone structures, peripheral nerves
the hand after
these [1]. Many of the problems that occur in
electi ve operat ive proce dure are related to
trauma or after an
y. The latter
the occurrence of pain and vascular insufficienc
or brief, or more prolo nged and associated
may be temporary
Our observa-
with edema or internal or external compression.
es show a direct relati onship betwe en altera-
tions and analys
the hand and
tions of arterial inflow and venous outflow of
nt of trauma
subsequent joint stiffness. The additional eleme
those tissue
and side effects associated with trauma aggravate
. Alterations
changes that are not always controlled completely
movement,
of cell membrane potentials, electrolyte shift, fluid
are a few of
both intracellular and extracellular, and vasospasm
the changes that are not easily controlled.

Vasoregulatory Conditions
The spectrum of the Raynaud phenomenon demonstrates
sensitive
the variations that occur in individuals who have a
may
vasoregulatory system. In the absence of trauma, a digit
ng of
become pale or white at one extreme or show slow blanchi
with
the nail beds at the other extreme. This interference
l
peripheral blood flow varies according to internal and externa
to
influences. Slight interference with blood flow may extend
temporary complete ischemia. If digits with these characteristics
are traumatized, they demonstrate significant change in skin
temperature and blood flow and are affected by secondary
changes in connective tissue. Also, in the patient with a known
systemic disease, hand stiffness is more likely to occur after
injury or after an elective operation than in those individuals
known to have consistently warm hands and no systemic
disease.

Other Factors Affecting Blood Flow

to or Within the Digits
Factors such as excessive ciagrette smoking, chronic atix-
iety, and those resulting in an individual who usually has cold
PREDICTORS/STORMY COURSE MWe

hands and feet may affect digital blood flow. Individuals with
these characteristics may develop more periarticular stiffness in
the injured hand than does the person who maintains hand
temperature closer to body temperature when subjected to
stress. Certain methods of treatment decrease the likelihood of
critical ischemia in these patients. Application of mild external
heat, avoidance of external compression, the use of vasodilator
medications and sympathetic and peripheral nerve blockage are
readily available methods of diminishing vasospasm. Patients
with chronic vasospastic problems may be helped by a
biofeedback program which provides increased hand tempera-
ture and decreased vasospasm, with associated diminution of
edema and a decrease in periarticular stiffness. The individual
who is to undergo an elective operative procedure may receive
traumatic incidents during the procedure, such as manipulation
of sensory or mixed nerves and closure of a tight wrist or
forearm compartment with resultant edema.
Individuals with a known systemic vascular condition such
as rheumatoid arthritis, lupus erythematosus or diabetes are
more likely to develop a complication if intraoperative trauma
occurs or if compartmental pressures are increased excessively
during the postoperative period [2].
These conditions may result in hyperesthesia or paresthesia
postoperatively, which causes secondary capillary construction,
diminished blood flow and cold intolerance. Joint stiffness may
occur if edema, pain and vasospasm are present simultaneously.
Once this occurs, afferent impulses are generated and the
patient builds up an “after image” of pain that may be
compared to the ‘“‘after image’? scotoma that occurs when an
individual looks directly into a bright light and receives a retinal
stimulus that results in a large purple spot, momentarily
interfering with clear vision.
If these afferent stimuli occur through pain receptors hour
after hour and day after day, the persistent pain causes
vasospasm and periarticular fibrosis. Marcaine* hydrochloride
or other pharmacologic agents that decrase pain postoperatively
will also diminish vasospasm. After an elective operative
procedure is completed, the goal is to maintain an ambient skin

*Rauwolfia.
 J. L. GOLDNER
14

Undesirable pressures
temperature and improve blood flow.
rm fascia or nonexpand-
may be due to tight antebrachial forea
ligam ents in the digits. An inade-
ing Cleland’s or Grayson’s
perat ive dress ing may cause excessive
quately prepared posto
pain, vasospasm and
external constriction which leads to
sensory nerve CO mpression .

Preoperative Assessment of Cold Tolerance

tolerate cold is
Information about the patient’s ability to
nse to stress of an
important in determining the possible respo
de a clue to the
operative procedure. The history will provi
the usual hand
occurrence of special problems. Ordinarily,
n about skin
examination is sufficient and includes informatio
skin color, joint
condition, sweating, speed of capillary refill,
of both overhead
mobility, the effect on peripheral circulation
these findings is
elevation and dependency, and pain. If any of
e recordings,
abnormal, then a cold tolerance test, pulse volum
l in determin-
Doppler readings and plethysmography are helpfu
ar abnormality.
ing either a vasoregulatory state or a true vascul
an unusual
Those patients with chronically cold hands, with
en disease have
amount of anxiety and with evidence of a collag
ive procedure
received a stellate ganglion block after an operat
25 years if
on the upper extremity at Duke during the past
this block was to
general anesthesia was used. The purpose of
vasoconstriction
warm the hand postoperatively, to decrease
by anatom ic placem ent of the anesthetic.
and to decrease pain
I am sugges ting interm ittent lowering of
For the same reasons,
in order to increas e the volume of
the elevated extremity
Althou gh ice may decrea se pain
inflowing arterial blood.
be placed around the hand postop era-
temporarily, it should not
vasosp asm may be harmfu l, even
tively since the resulting
ts from prolon ged coolin g in
though the physiologic benefi
are recogn ized. The advant ages and
decreasing metabolic rate
ion of
disadvantages of cooling depend on the pathologic condit
potent ial for blood flow and the
the hand, the patient’s age, the
cause of pain.
e
Stellate ganglion blockade has proven to be a valuabl
s of the sympath etic fibers
procedure postoperatively. Paralysi
and
results in dilation of the peripheral arterioles, venules
capillaries. Also, the anesthetic materia l injecte d in the region of
PREDICTORS/STORMY COURSE 15

the stellate ganglion affects the sensory fibers of the adjacent

brachial plexus and diminishes pain and vasospasm. In the past,
I have used stellate ganglion block at the end of the operative
procedure on the hand, forearm and elbow if the patient has
received a general anesthetic. This procedure for obtaining
vasodilation and decreasing vasospasm is still performed. How-
ever, as the use of axillary brachial block with longer-acting
anesthetic agents has increased, the patient has a relatively
prolonged sympathetic blockade after tourniquet release and
for a few hours after leaving the operating room. Stellate
ganglion blockade will be used several hours after the brachial
blockade has worn off if necessary. This valuable procedure is
used in the aging individual after wrist or hand injury or after an
elective | procedure not performed under axillary block. For
example, a 70-year-old woman with a Colles fracture is managed
immediately after manipulation of the fracture and immobiliza-
tion by splitting dressings and spreading splints to avoid edema
of the hand, by intermittent elevation and neutral positioning
of the hand, and by recognizing progressive median nerve
compression if it occurs and relieving this pressure by operative
means if necessary. Sympathetic blockade aids in preventing
swelling of the fingers, increases blood flow and decreases pain.
Intravenous or intraarterial reserpine provides an additional
method of diminishing vasospasm and providing a prolonged
sympathetic blockade. The intravenous Xylocaine technique is
performed by the same technique used in obtaining intravenous
anesthesia on the arm and hand. A double tourniquet is placed
around the arm, 50 cc of 0.4% Xylocaine containing 2.5 mg of
reserpine* is injected intravenously after the upper extremity
has been exsanguinated, and the tourniquet is elevated. The
reserpine is added to the solution to provide a sympathetic
blockade effect in the forearm and hand. The tourniquet is left
in place for at least 25 minutes so that the Xylocaine and
reserpine become fixed in the local tissues. The evidence of
‘vasodilatation may last from one to three weeks.
This combination of alternate elevation and dependent
position of the hand and arm; warming of the hand by external
dressings and avoiding ice; decreased use of vasospastic pharma-
cologic agents, such as nicotine and other vasoconstricting

*Rauwolfia.
16 J. L. GOLDNER

as
drugs; and the early use of sympathetic blockade, either
stellate ganglion block or reserpine or both, will protect the
patient from chronic vasoconstriction, decrease pain and dimin-
ish the likelihood of development of reflex sympathetic
dystrophy.

Patient Examples Illustrating Development

of a Sympathetic Dystrophy Syndrome

Case 1
A 35-year-old woman received a crushing injury to her
right little finger. The flexor tendons were lacerated,
primary repair was attempted, but infection occurred. Pain
was constant, and digit and joint stiffness developed within
a few days after the injury. Also, the patient had a high
level of anxiety and was a heavy smoker. After several
weeks, because of failure of tendon repair, a silicone rod
was inserted in an effort to improve range of motion and
to form a tendon sheath for eventual tendon grafting. The
rod extended to the lower forearm, thereby increasing the
volume of tissue within the carpal canal. Postoperatively
the patient complained of severe pain, tightness of the
hand and fingers, burning in the hand and progressive
inability to sleep because of the pain. The dressing was
described as a few small sponges, a wrap-on gauze bandage
and an elastic bandage. Tight external bandages placed on
a fibrotic hand with a full carpal canal may cause median
nerve compression, vasospasm and pain. Elastic bandages
and tight gauze bandages tend to constrict rather than
expand when postoperative edema occurs. Perfusion is
limited and periarticular tissues stiffen in this effort to
prevent edema. This patient, in retrospect, had median
nerve compression with resulting burning, tingling and
secondary vasospasm. A vicious cycle occurred as a result
of increased lower forearm and hand compartment pres-
sure, with subsequent decreased capillary perfusion; severe
pain and a “reflex sympathetic dystrophy” had developed
within 72 hours after the operative procedure. The
extremity then went through three phases of dystrophy,
with eventual severe limitation of joint motion; smooth,
shiny skin; and excessive sweating.
PREDICTORS/STORMY COURSE iy,

Examination of the hand during this third phase

showed the radial and ulnar pulsations to be intact, but the
fingertips showed slow recovery of color after pressure.
Skin temperature readings were diminished 3 C when the
hand was in a neutral position and if elevated for two
minutes or longer, the skin temperature dropped signifi-
cantly. A percussion test over the median nerve caused
paresthesias in the fingers and the same occurred when the
ulnar nerve was tapped. Interphalangeal joint motion was
decreased, metacarpophalangeal joint motion was dimin-
ished and total hand stiffness had occurrred. The hand
demonstrated unusually rapid colling and slow warm-up
capability. This patient’s problem resulted from a com-
bination of mechanical compression of the median nerve,
externally and internally, edema, infection, persistent
vasospasm and resulting sympathetic dystrophy.
Treatment during the chronic phase necessitated de-
compression of the median and ulnar nerves, eventual
deletion of the fifth ray, release of contracted metacarpo-
phalangeal joint ligaments and capsule, repeated stellate
ganglion blocks, anti-inflammatory agents and persistent
external splinting and exercise. A functional hand was
eventually obtained, but only after a period of three years
from initial injury to final assessment.

Case 2
A 45-year-old woman received a hand injury when a
20-pound weight contused her little finger after the weight
fell from a height of about 3 inches. The initial injury did
not appear to be serious; there was neither a fracture nor
an obvious joint injury and swelling was not severe,
althought the range of finger motion was limited signifi-
cantly shortly after the injury. The patient reported to the
industrial nurse at the plant. After the nurse recorded
information about the injury she applied an elastic
bandage to the hand. This external compression was
greater around the wrist and forearm than over the hand
and generalized edema occurred within 24 hours. This was
accompanied by tingling of all the fingers, burning of the
entire hand and limited finger flexion. Joint stiffness
increased rapidly and swelling of the dorsum of the hand
 J. L. GOLDNER
18

occurred. Pain, paresthesias, edema, joint stiffness and cold

intolerance were the characteristics associated with this
patient’s pain syndrome.
A cold tolerance study performed several months after
the initial injury showed excessively rapid cooling of the
hand after a few minutes of exposure to cold, severe pain
in the hand as cooling occurred and a slow warm-up time.
The opposite, uninvolved hand showed a much slower
cooling time, less pain at the extremes of cooling and more
rapid warm-up of the patient’s hands. The uninvolved
hand, when compared with the involved hand, showed: the
latter to be very slow in returning to ambient temperature
after the cooling test was performed. These findings
indicated that a vasospastic condition persisted, that nerve
conduction was slow during cooling and that collagen
tightness became progressively worse as vasospasm per-
sisted. Emotional factors such as anxiety and apprehension
contributed to the vasospasm and indirectly may have
affected the severity of the syndrome. As fibrosis oc-
curred, the pain was further aggravated by contracture of
synovial and fibrous tissue, by nerve compression syn-
dromes and by a combination of these factors. Further-
more, diminution of pain after sympathetic blockade is
not predictable and much less successful than when the
blockade is done during phase I or II of the dystrophy
syndrome.
Management of this particular patient was difficult
because she would not tolerate injections of any kind,
refused stellate ganglion blockade, reacted histrionically
when nerve blocks were attempted and showed no
improvement with external splinting or formal physical
therapy. All invasive forms of therapy necessitated a
general anesthetic, and this fact delayed her overall
treatment. This patient demonstrated several different
etiologic factors, all of which culminated in a sympathetic
dystrophy syndrome involving hand, wrist, forearm, elbow
and shoulder. Since this patient was already in phase III of
the dystrophy syndrome and since sympathetic blockade
done even under general anesthesia was not helpful to her,
the evidence did not favor a sympathectomy. Although
PREDICTORS/STORMY COURSE 19

sympathectomy may be successful in decreasing or even

eliminating vasospasm, the changes that might occur as a
result of diminishing stimulation of the sympathetic fibers
and the secondary effects resulting from sympathectomy
are not always desirable. The predictability of the pro-
cedure to relieve pain varies according to the stage of the
syndrome which exists at the time the procedure is
performed. There are successful alternatives to surgical
sympathectomy, such as the use of intraarterial or intra-
venous reserpine and other pharmocologic and physical
agents.

Discussion of Sympathetic Dystrophy

Why* does a relatively minor injury result in these cata-

strophic changes? The peripheral and central nervous system
receive and transform painful sensations and, depending on the
severity of the original injury and the duration of the stimuli,
the patient responds in many different ways. Receptors such as
unmyelinated nerve fibers, pacinian corpuscles and Meissner’s
corpuscles receive different stimuli, or the same stimulus, and
respond at different levels. These receptors and the action of
the posterior sensory ganglion and the effect on the sympa-
thetic fibers in the reflex arc register awareness in the spinal
cord at one time and in the brain at a different level. The
mechanism as described appears to be relatively uncomplicated
but, in fact, the complexity of the problem is overwhelming.
The syndrome may result from a combination of external
trauma, internal painful stimuli, pharmacological agents causing
vasospasm, and sympathetic stimuli causing vasospasm. Pre-
vention or relief of the syndrome requires a program that
relieves pain, diminishes edema, avoids vasospasm, neutralizes
the overactivity of sympathetic fibers and lessens anxiety.

Preoperative Testing of Cold Tolerance

and Blood Flow

The Allen compression test is performed at the wrist and at

the base of individual digits. Patency of the radial and ulnar
arteries at the wrist is determined by having the patient open
and close the fingers and make a forcible fist. While the fingers
20 J. L. GOLDNER

are flexed, the examiner compresses the radial and ulnar arteries
at the wrist and the patient is then asked to open the hand but
not forcibly to extend the fingers. The ulnar artery compression
is released but the radial is maintained. If paleness of the palm
persists, then flow through the ulnar artery is delayed or absent.
Compression of the radial artery is then released and the skin
becomes pink, depending on the rapidity of filling of the hand
through the radial artery [2].
The same test is performed at the base of each digit by
compressing the blood out of the digit with the examiner’s
thumbs and compressing both digital arteries at the base of the
patient’s digit. Then one thumb is elevated to allow blood flow
through this artery and the examiner determines whether that
side of the finger shows evidence of blood flow either quickly
or slowly, or not at all. The other digital artery is then tested in
a similar way. Previously traumatized digits may show one
artery functioning and one blocked or both arteries may have
minimal or no active flow. Collateral circulation may be
sufficient to maintain viability of the digit, but trauma or
placement of incisions may jeopardize the finger. A digit
without arteries will usually recover its blood flow after the
tourniquet is released but the recovery time is considerably
slower than normal. Digits with significant diminution of blood
flow but which are subjected to operative reconstruction
frequently show reactive fibrosis, adherence of collagen and
limited tendon excursion and joint function. If reasonable
circulation is not assured to a digit, then a major reconstructive
procedure should not be performed. A cold tolerance study will
show rapid cooling and significant pain.
Other factors that may cause postoperative pain and affect
the patient adversely are compression of a sensory cutaneous
nerve, traction on a major mixed nerve or interference with
blood supply to a skin flap or a mild cutaneous flap. Trauma to
the median nerve, the sciatic or obturator nerves may cause
major causalgic syndromes since these nerves contain their own
central artery and, if damaged, may have significant ischemia
resulting in persistent paresthesia, dysesthesia, temporary in-
farct of the nerve or temporary vasospasm. The last causes pain
which in turn aggravates vasospasm, with resulting decreased
blood flow and periarticular fibrosis.
PREDICTORS/STORMY COURSE all

Closure of contaminated wounds or wounds without ade-

quate skin relaxation may cause peripheral nerve ischemia or
pressure, infection or skin necrosis. These wounds should be left
open and skin grafted; in managing these problems delayed
closure is helpful in preventing severe pain and sympathetic
dystrophy.
Multiple tendon transfers about the wrist and hand will
increase the volume of the forearm compartment, fill up the
carpal canal and indirectly compress the median or the ulnar
nerve. If Curing a postoperative period the patient complains of
paresthesias and progressive pain, then the dressing should be
relieved and, if necessary, the wound reopened and the carpal
canal and fascia in the distal forearm released.
4

Compartment Syndromes

If a patient complains postoperatively of unbearable pain,

burning in the fingers or inability to flex or extend the fingers,
the surgeon must assume that there is persistent irritation of
soft tissue within a closed compartment or some other cause for
the pain. External compression may be excessive, internal
compression may be progressive and both of these require
immediate action. Compartment pressures can be measured or
the surgeon may act on the clinical examination and patient’s
complaints. The patient with pain must be managed immedi-
ately and not by opiates or long-acting anesthetics. There is a
current trend to use long-acting anesthetics postoperatively as
this may be helpful in certain conditions, but this procedure
may also mask pain and mislead the surgeon into believing that
the patient is totally comfortable when, in fact, the anesthetic
action may mask a tight dressing or a compressing compart-
ment. The patient’s capability of complaining of pain should
not be masked by systemic medications or local infiltrations.

Terminology — Differential Designation

‘“‘Causalgia”’ is a specific condition associated with nerve

injury, characterized by burning pain in the autonomous zone
in
of that nerve. S. Weir Mitchell described the condition
and lower extremiti es
soldiers who had injuries to the upper
The
involving particularly the median or sciatic nerves [3].
22 J. L. GOLDNER

to
causalgic state of peripheral burning and paresthesia enlarges
excessiv e sweatin g, joint stiffnes s and
include hyperesthesia,
patient intolerance to noise or changes in environmental
temperature. My observations indicate that this syndrome is
usually associated with diminished blood flow as a result of
combined nerve and vascular injury which responded to
sympathectomy. For the purposes of definition, causalgia is
used to describe the burning pain, but other aspects of the
syndrome must be described by terms that relate to the
particular deficiency.

Terminology of Syndromes
Cold intolerance occurs with isolated nerve injury, vascular
damage, collagen disease or vasospasm secondary to pharma-
cologic agents or anxiety. The rapidity of cooling and warm-up
can be recorded and the onset of pain and the severity of pain
equated to the cooling [4].
Sudeck atrophy is the loss of bone density that occurs with
pain syndromes, immobilization of the hand in a splint or
decreased bone density that occurs with loss of muscle mass,
misuse of the part and pain. This bone atrophy is a part of the
sympathetic dystrophy syndrome or the total causalgic syn-
drome.
Reflex sympathetic dystrophy refers to the syndrome that
occurs after trauma or pain or an exciting stimulus which causes
overactivity of the sympathetic nerves and primary or second-
ary vasospasm. A cool hand, excessive sweating, periarticular
fibrosis and pain in the fingers, wrist and more proximally
characterize the late phase of the condition.
Shoulder-hand syndrome is a variant of reflex sympathetic
dystrophy with mild, moderate or severe changes in the hand,
wrist and shoulder of periarticular fibrosis, cold intolerance,
vasospasm, diminished peripheral blood flow and pain.
Sympathetic dystrophy is frequently associated with an
operative procedure or an injury and includes several of the
pathologic alterations already designated as part of other
syndromes mentioned. The spectrum of sympathetic dystrophy
is acute, subacute and chronic, and the characteristics demon-
strated by the patient will vary according to the severity and
duration of the condition.
PREDICTORS/STORMY COURSE Ds}

Compartment pressure syndrome. Peripheral nerve compres-

sion, muscle fibrosis and secondary periarticular fibrosis cause
pain, limitation of motion, and limitation of strength and
motion that are somewhat similar to the dystrophic syndromes.
Vasospasm, decreased peripheral blood flow, may cause pares-
thesias, but the aching and pain associated with connective
tissue fibrosis is a source of pain not improved by improving
peripheral blood flow such as would occur with sympathectomy
or use of B-blocking pharmacologic agents that might cause a
sympathetic effect. Peripheral nerve decompression, tendon
lengthening and release of fibrous contractures are essential
steps in decreasing pain and improving range of motion [5].

P Postoperative Management

The complexity of the entire problem becomes evident as

one attempts to treat the patient with a persistent pain
syndrome. The surgeon must be vigilant in order to prevent
pain, edema, vasospasm and ischemia, all of which are caused by
many different conditions and none of which respond consist-
ently to a single method of treatment.
Postoperative or posttraumatic management must consider
the following:
1. Avoid constricting elastic bandage; tight, unyielding
dressings; rigid casts that have not been split; and
uneven compression from cotton wrapping that be-
comes rigid after absorbing blood and tissue fluid.
2. Avoid internal compartment and nerve pressure by
appropriate release of fascia and fibrous tissue covering
nerves and vessels.
3. Diminish pain by improving blood flow, decreasing
pressure, adequate immobilization and appropriate med-
ication.
A. Diminish vasospastic pharmacologis agents such as nico-
tine, ergot and substances that cause vasospasm.
5. Diminish anxiety by reassurance, sympathy, empathy
and communication with the person.
of
6. Avoid constant elevation; encourage active motion
the shoulder, elbow, wrist, hand and fingers; and
mobilize the patient.
 J. L. GOLDNER

References

. Goldner, J.L.: Volkmann’s ischemic contracture. [n Flynn, J.E. (ed.):

Hand Surgery ed. 2. Baltimore: Williams & Wilkins, 1975.
. Goldner, J.L. and Eguro, H.: Bilateral thrombosis of the ulnar arteries
in the hands. Case reports. Plast. Reconstruct. Surg. 52 (5):573-578;
1973.
. Mitchell, S.W.; Injuries of the Nerves and Their Consequences.
Philadelphia:J. B. Lippincott Co., 1872.
. Goldner, J.L., Urbaniak, J.R., Bright, D.S. et al: Sympathetic dys-
trophy — Upper extremity: Prediction, prevention, and treatment.
Paper presented at the Annual Meeting of the American Society for
Surgery of the Hand, Atlanta, Feb. 1980.
. Goldner, J.L. and Bright, D.S.: The effect of extremity blood flow on
pain and cold tolerance. Jn Omer, G. and Spinner, M. (eds.): Peripheral
Nerves and Their Management. Philadelphia:W. B. Saunders, 1980.

Self-Evaluation Quiz

An individual’s ability to tolerate pain is unpredictable.

a) True
b) False
Tingling and burning in the fingers result from nerve injury
only.
a)eeLrte
b) False
Nicotine causes vasodilatation of peripheral arterioles.
AjeeLrue
b) False
The ability to tolerate cold environment is dependent only
on the condition of the peripheral blood vessels.
ajeslrue
b) False
Severe postoperative pain is best treated by opiates.
a) True
b) False
Evidence of progressive compression of the median nerve
postoperatively requires urgent action and may necessitate
which two of the following?
a) Higher elevation of the extremity
b) More opiates
c) Release all external dressings
d) Surgical release of the median nerve
PREDICTORS/STORMY COURSE 25

7. A prior history of severe pain and stiffness of the hand after

an injury is helpful in determining whether the patient is at
high risk of developing problems after an operation.
a) True
b) False
8. Postoperative management of a patient with known collagen
disease who develops diminished blood flow to the hand, as
evidenced by cool fingers, pain and slow nail-bed blanching
would include, in order of preference early and late:
a) Arteriogram
b) Stellate ganglion block
c) Intravenous or intraarterial reserpine in extremity
d) 6-Blocking agent (Priscoline, Dibenzyline)
4

Answers on page 527.

 Postoperative Management
of Tenolysis
Evelyn J. Mackin, L.P.T.

Objectives
The key to improved results in flexor tenolysis is active
participation by the patient during surgery and early active
motion postoperatively. The goals of the surgeon and
therapist in the operative and postoperative phases of flexor
tenolysis are discussed. The surgeon works closely with the
therapist in the postoperative management.

Successful results from tenolysis depend in great measure on

early postoperative motion [1, 2], which is not always possible
to achieve with some patients. Children will not exercise if “‘the
finger hurts,” and patients have different tolerances to pain. It
is not unusual for a burly, 300-pound truck driver to freeze
with fear and stare at his hand or the therapist when he is asked
to flex his finger!
Nongliding adhesions form along the surface of a tendon
after injury or repair. When these tendons cannot be mobilized
by therapy techniques, surgical lysis of these adhesions will in
most cases increase active range of motion and improve hand
function.
Tenolysis may be performed three months after tendon
repair and about six months after tendon grafting. During this
period, the emphasis is on gaining as much passive range of
motion as possible. A hand therapy program should include
active and passive exercises to all involved joints, several times a
day. Whirlpool and lanolin massage will help to facilitate passive

Hand Therapy, Hand Rehabilita-

Evelyn J. Mackin, L.P.T., Director,
tion Center, Ltd., Philadelphia, Pa.

27
28 E. J. MACKIN

motion in stiff fingers. Splinting may be necessary to correct

flexion deformities.
Active participation of the patient during the surgery
procedure is the key to improved results in flexor tenolysis.
This is achieved through the use of local anesthesia supple-
mented by an intravenous analgesic-tranquilizer combination
drug [3]. Easily awakened, the patient cooperates dynamically
in the surgery as the motion-limiting adhesions are methodically
excised. The surgeon can thus be sure that the tendon has been
completely freed and that the motor muscles can actively pull
the finger fully into flexion. The patient’s active flexion to the
distal palmar crease is measured and recorded, providing a basis
for assessment of the final result.
After tenolysis, Marcaine* nerve block anesthesia is effect-
ive in helping the patient during the discomfort of the early
postoperative days. The advantage of Marcaine anesthesia is that
an early active-motion program may be initiated on the first
postoperative day. However, postoperative management must
be carefully monitored by the surgeon and therapist. Since
tenolysis devascularizes and weakens the tendon, rupture
through the lysed area can occur during this period. The
surgeon must describe to the therapist the condition of the
tendon and specify exactly how much stress can be safely
applied.
At surgery a soft Silastic rubber Jackson-Pratt catheter is
placed proximal to the sensory nerves of the tenolysed finger.
Through this catheter, Marcaine 0.5% is instilled at the rate of 1
or 2 cc about every four hours, by the patient. A stronger
concentration might produce a chemical irritation of the soft
tissues. The syringe containing the Marcaine is taped to the
patient’s arm (Fig. 1). The catheter is left in place for five days
after surgery and the Marcaine is slowly injected by the patient
several minutes before the exercise period. The patient is taught
how to inject himself. For the first two injections he is
supervised by the physician or therapist. While the catheter is in
place in the forearm or palm, the patient receives prophylactic
antibiotics. When the catheter is removed, usually after five
days (Fig. 2), an antibiotic ointment is applied to the catheter
*Marcaine hydrochloride. Winthrop Laboratories, Division of Sterling
Drug, Inc., New York, NY 10016. 0.5% Marcaine is mixed in the operating
room. Marcaine is a long-acting local anesthetic.
POSTOPERATIVE MANAGEMENT OF TENOLYSIS 29

FIG. 1. Syringe containing Marcaine is taped to the patient’s arm.

FIG. 2. The Marcaine catheter is removed after five days.

 E. J. MACKIN
30

site. By this time, the patient should have attained the active
range-of-motion potential achieved at surgery. Some patients
find that when they have “worked through”’ the discomfort of
the first few days, they do not need Marcaine as often.
However, with most patients, it is wise to leave the catheter in
for the five-day period, to assure their capability to carry out
the necessary exercises.

Postoperative Therapy

Postoperative treatment varies according to the surgical

procedure. The patient is seen by the therapist daily during the
first week. The first session of therapy consists primarily of
careful instruction in an exercise regimen and encouraging the
patient to move. The patient must fully understand that if good
results are to be obtained from the tenolysis procedure, flexion
exercises emphasizing full grip must be carried out immediately
and on a regular basis during the first postoperative week. He
should also understand that the tendon bed must reorganize
with a sliding cell system that will lubricate and give fluid
nutrition to the lysed tendon. Only the patient can accomplish
this, through active muscle contraction that moves the tendon
and joints.
Treatment by the hand therapist begins one day postopera-
tively. The large, bulky, compressive gauze dressing applied
during surgery is removed, and the extremity is placed on a
sterile field. The gauze covering the incision line is left on as a
protective covering for several days, until it separates from the
wound site and is easily removable. The patient is given 1 cc of
Marcaine; as soon as the involved finger is numb, treatment may
begin. First, the therapist should apply sterile gloves to protect
the incision and catheter from contamination. Sutures are not
removed for at least two weeks to guard against wound
dehiscence. Whirlpool is not permitted until the incision has
healed. During the early postoperative days the hand is elevated
in a Zimmer sling,* in a hand-above-the-heart position.
It is extremely important that the exercise program be
written out as well as explained verbally, since it will be carried
out by the patient at home. It consists of the following:

*Zimmer sling. Zimmer-Rodewalt Associates, Inc., 18 E. Centre Street,

Woodbury, NJ 08096.
POSTOPERATIVE MANAGEMENT OF TENOLYSIS Sul

iy Passive flexion of the involved distal interphalangeal,

proximal interphalangeal and metacarpophalangeal
joints.
Active flexion of the involved distal interphalangeal,
proximal interphalangeal and metacarpophalangeal
joints.
Gentle passive extension of any proximal interphalan-
geal contractures of the joints, with the wrist and
metacarpophalangeal joints in flexion.
Active extension of the involved distal interphalangeal,
proximal interphalangeal and metacarpophalangeal
joints.
Isolated sublimis function.
Passive fist-making. Patient presses involved hand into a
fist with uninvolved hand (or therapist does so), then
releases opposite hand and tries to retain tight fist with
his own muscle power (Fig. 3). Passive fist-making
exercise is done ten times every hour. Postsurgical
edema is reduced by early fist-making. Fist-making
milks the hand and aids venous flow.

involved hand into a

FIG. 3. Passive fist-making. Therapist presses patient’s
Therapi st then releases hand and patient tries to retain tight fist with
fist.
his own muscle power.
 E. J. MACKIN
32

FIG. 4. Distal interphalangeal passive cuff.

POSTOPERATIVE MANAGEMENT OF TENOLYSIS Bs!

7. Distal interphalangeal flexion.

8. Flexion of the distal interphalangeal joints so that the
finger pulps touch the metacarpophalangeal crease.
9. Active fist-making — flexion of the distal interphalan-
geal joints and rolling in the fingertips to make a tight
fist.
These exercises must be repeated ten times, four times a
day. The patient will inject 1 cc of Marcaine prior to the
exercise period. This home program is of the utmost importance
if the patient is to retain the range of motion obtained at
surgery. Following the exercise session an antibiotic ointment is
applied to the catheter site and the suture line. A sterile dressing
applied on the incision must not restrict the patient’s home
program.,
Assistive passive extension splinting may be necessary to
correct flexion contractures when permitted by the surgeon.
Satisfactory devices include the Joint Jack* and Zimmer
Aluminum- Foam splints.+ Assistive passive flexion devices may
also be necessary, such as the web strap [4] and the distal
interphalangeal passive flexion cuff. To achieve greater flexion
of the distal and proximal interphalangeal joints of the finger, a
distal interphalangeal passive device may be used to permit
graduated flexion of the small joint (Fig. 4).
The patient is closely guided through the postoperative
weeks while the active range of motion attained at surgery is
being maintained. A program of graded grip-strengthening
activities is initiated at four to six weeks. Heavy work is usually
not permitted until eight weeks after surgery.
No complications have been noted with the use of sub-
cutaneous Marcaine catheters with this protocol. Some patients
have a minimal pain problem following surgery and, after
successful movement trials without regional anesthesia, may
request removal of the catheter. The surgical team has expressed
no regrets with early removal, feeling that it is better to have all
postoperative options open after precise and time-consuming
surgery.
*Joint Jack, Joint Jack Company, 198 Millstone Rd., Glastonbury, CT
06033.
Associates, Inc.,
+Zimmer Aluminum-Foam Splint. Zimmer-Rodewalt
18 E. Centre St., Woodbury, NJ 08096.
 E. J. MACKIN
34

References

1. Schneider, L.H. and Hunter, J.M.: Flexor tenolysis. Jn American

in
Academy of Orthopaedic Surgeons Symposium on Tendon Surgery
the Hand. St. Louis:C. V. Mosby Co., 1975, vol. 18, p. 157.
2. Schneider, L.H. and Mackin, E.J.: Tenolysis. In Hunter, Schneider,
V.
Mackin and Bell (eds.): Rehabilitation of the Hand. St. Louis:C.
Mosby Co., 1978, pp. 229-234.
anal-
3. Erickson, J.C. III, Hunter, J.M. and Schneider, L.H.: Neurolept
gesia and Local Anesthesia for a Dynamic Approach, videotape.
Philadelphia: Dept. of Anesthesiology & Orthopedic Surgery, Jefferson
Medical College.
4. Mackin, E.J.: Hand therapy program for shaped tendon grafting using
gliding tendon implant (Hunter design). This volume.

Self-Evaluation Quiz

1. Active participation of the patient in the surgery procedure

is the key to improved results in flexor tenolysis.
a) True
b) False
2. All patients have the same tolerances to pain.
a) True
b) False
3. 0.5% Marcaine, a long-lasting local anesthetic, helps the
patient during the discomfort of the early postoperative
days.
a) True
b) False
4. The advantage of Marcaine anesthesia is that an early
active-motion program may be initiated on the first post-
operative day.
a) True
b) False
5. At surgery, a catheter is placed proximal to the sensory
nerves of the tenolysed finger. The syringe containing the
Marcaine is strapped to the patient’s arm. The Marcaine is
slowly injected by a nurse several minutes before each
exercise period.
a) True
b) False
6. 0.5% Marcaine is instilled at a rate of 1 or 2 cc about every
four hours.
POSTOPERATIVE MANAGEMENT OF TENOLYSIS 3D

a) True
b) False
7. While the catheter is in place in the palm or forearm, the
patient receives prophylactic antibiotics.
a) True
b) False
8. The therapist uses sterile technique (sterile field and gloves)
during treatment to protect the incision and catheter from
contamination.
a) True
b) False
9. The catheter is usually removed at two days.
a) True
b) False
10. A home exercise program is of the utmost importance.
a) True
b) False

Answers on page 527.

Soft Tissue Injuries of the Hand
 Vincula in No-Man’s Land

Naoyuki Ochiai, M.D., Takeshi Matsui, M.D.,

Robert J. Merklin, M.D., James M. Hunter, M.D.
and Glenn A. Mackin, B.A.

Objective
Primary repair of lacerated flexor tendons in no-man’s
land continues to be a difficult surgical problem and
continues to be associated with an uncertain prognosis. In
this area of the normal finger, both flexor tendons slide
through a narrow digital canal, where a complicated
vincular system exists that is said to support the blood
supply to the flexor tendons. Knowledge of precise
anatomic details of this area would seem essential for good
surgical results.
The purpose of this paper is to clarify the morphologic
anatomy of the vincular system in no-man’s land.

Materials and Methods

Thirty-five human upper extremities from cadavers or

traumatic, amputated specimens were used. The patients’ ages
ranged from 11 months to 88 years. All specimens were injected
with diluted Indian ink-Latex solution through major arteries
fixed
by means of hand syringes and manual pressure and then
cleared with
with 10% formalin. After dissection, they were
11:2 solution of tricresyl-phosphate-tributyl-phosphate (Caplan
75). A total of 130 fingers was available for study.
Findings
the common
Three transverse communicating branches of
beeen described [1]. The distal branch is
digital artery have
Robert J. Merklin, M.D.,
Naoyuki Ochiai, M.D., Takeshi Matsui, M.D.,
Hunter , M.D. and Glenn A. Mackin , B.A., Thomas Jefferson
James M.
University, Philadelphia, Pa.
c Journal 7 (1):33-40, 1978.
Reprinted from The Jefferson Orthopaedi

39
40 N. OCHIAI ET AL

located at the neck of the middle phalanx, the interphalangeal

branch is located at the base of the middle phalanx, and the
proximal transverse branch is located at the neck of the
proximal phalanx. The authors have found a fourth transverse
communicating branch of the common digital artery at the base
of the proximal phalanx. All these communicating branches
seem to have an important relationship to the vincular system
of the flexor tendon.
In the digital canal, both flexor tendons had two kinds of
vincula, the short and long vincula which were folds of the
mesotendon. The short vinculum of the superficialis tendon
arose from the membranous part of the volar plate of the
proximal interphalangeal joint and attached to the decussation.
This sort vinculum contained many arterial vessels which came
mainly from the proximal transverse digital artery. The short
vinculum of the profundus tendon or the thin triangular-shaped
mesotendon arose along the distal two thirds of the middle
phalanx. The arterial supply to this vinculum came mainly from
both the interphalangeal and distal transverse digital arteries.
These two short vincula were consistently found in all dissected
fingers (Fig. 1).
In the present study, the long vincula, which have been
considered to be major channels of the segmental blood supply
to the flexor tendons in the digital canal, were found to be of
various types and to differ from each other in the four fingers
studied. The authors found and classified three types of
distribution of the studied long vincula of the superficialis
tendon and five types of distribution of the long vincula of the
profundus tendon (Fig. 2).
The long vinculum of the superficialis tendon arose from
the transverse communicating artery at the radial or ulnar side
of the base of the proximal phalanx and attached to one of two
slips of the superficialis just proximal to the decussation. These
two long vincula were classified as the radial and ulnar type,
respectively. The radial type was found in 67 and the ulnar type
was found in 65 of the 1380 fingers studied. Thirty-seven of
these fingers had both radial and ulnar types. No long vinculum
was found in 35 fingers and was considered absent.
The five types of distribution of the long vincula in the
profundus tendon were named as the distal, middle, mixed,
 Dist. Trans. Dig. A.

Inter. Trans. Dig. A.

Prox. Trans. Dig. A:

Branch to WLS

Common Dig. A.

FIG. 1. These schemes show the relationship between the flexor tendons,
vincular system, four transverse communicating arteries and the pulleys.
VLP: Long vinculum of the profundus. VLS: Long vinculum of the
superficialis. VBP: Short vinculum of the profundus. VBS: Short vinculum
of the superficialis. Five annular pulleys are shown as A-1 to A-5, and
three cruciform pulleys as C-1 to C-3.

vLP
1, Distal Type
2, Middle Type
3, Proximal Type
4, Mized Type
5, Absent

VLS
(1), Radial Type
(2), Ulnar Type
(3), Absent

FIG. 2. This scheme shows

five types of long vincula
of the profundus and three
types of long vincula of
Middle Phalanx
the superficialis and their
localization.
492 N. OCHIAI ET AL

proximal and absent long vicula (Fig. 2). The distal type arose
at the level of the insertion of the superficialis tendon and
attached to the profundus tendon directly. Its blood supply
came mainly from the interphalangeal transverse digital artery.
This type was very rare and was found in only seven of the 130
fingers studied (Fig. 3).
The middle type bridged between the profundus and the
decussation of the superficialis tendon as the direct continua-
tion of the short vinculum of the superficialis. Its blood supply
came from the proximal transverse digital artery (Fig. 4). This
type was the most common type and was found in 95 of the
135 fingers studied.
The proximal type arose from the synovial membrane
between the two slips of the superficialis and attached to the
profundus where it passed through the superficialis. Its arterial
supply came from the long vincula of the superficialis tendon
(Fig. 5).
The mixed type had the same relationship to the two
tendons as the proximal type, but in this type there were no
long vincula of the superficialis. Its blood supply came from the
short vincula of the superficialis indirectly through the synovial

ie Piel
FIG. 3. Distal type of the long vinculum of the profundus.
VINCULA IN NO-MAN’S LAND 43

FIG. 4. The middle type of the long vinculum of the profundus continues
to the short vinculum of the superficialis.

of

long vinculum of the

FIG. 5. Blood su pply of the proximal type of the
long vincul um of the superficialis.
profundus comes mainly from the
44 N. OCHIAI ET AL

membrane between the two slips of the superficialis (Fig. 6).

This type was found in 20 of the 130 fingers studied. The ring
finger was involved in 13 instances.
No long vinculum was found in eight of the 130 fingers
studied and was considered as absent (Fig. 7). Multiple vincula
were occasionally seen, especially in the middle type of long
vinculum of the profundus.
Analysis of 33 index, 33 long, 30 ring and 34 little fingers
indicates various combinations of these five types of long
vincula supplying the profundus and three types of long vincula
supplying the superficialis. However, in each of the four fingers
studied, certain patterns of supply seem to be prevalent.
In the index finger the most common combination was the
middle-type long vinculum of the profundus and the radial-type
long vinculum of the superficialis. This combination was found
in 12 of 33 index fingers studied. The second most common
combination was the middle-type long vinculum of the pro-
fundus and both the radial and ulnar types of long vincula of
the superficialis; this was found in 7 of 33 index fingers studied.
If one looks only to the long vincula of the superficialis tendon,

FIG. 6. Mixed type of the long vinculum of the profundus and absent type
of the long vinculum of the superficialis.
VINCULA IN NO-MAN’S LAND 45

FIG. 7. There were neither the long vincula of the profundus nor of the
superficialis.

the radial type was found in 15 and both radial and ulnar types
were found in 13 of the 33 index fingers studied.
In the long finger, a combination of the middle-type long
vinculum of the profundus and the radial-type long vinculum of
the superficialis was found in 5 of 33 long fingers studied. A
combination of both middle and proximal types of long vincula
of the profundus and the radial and ulnar type of long vincula
of the superficialis was also found in five fingers. There was no
one dominant combination in the long finger. The special
combination of the absent types of both the profundus and
superficialis was found in three long fingers.
In the ring finger, the mixed-type long vincula of the
profundus was found in 13 of 30 fingers studied. In 18 of 30
fingers studied, no long vinculum of the superficialis was found.
The combination of the middle and mixed type of long vincula
of the profundus and the absent-type long vinculum of the
A
superficialis was found in 6 of the 30 ring fingers studied.
pe long vinculum of the profundu s
combination of the mixed-ty
tendon
and the absent-type long vinculum of the superficialis
was also found in 6 of the 30 fingers studied.
46 N. OCHIAI ET AL

In the little finger, the combination of the middle-type long

vinculum of the profundus and the ulnar-type long vinculum of
the superficialis was found in 12 of 34 fingers studied. A
combination of the middle and proximal type of long vincula of
the profundus and ulnar-type long vinculum of the superficialis
was found in 7, and a combination of the middle-type long
vinculum of the profundus and the radial and ulnar type of long
vincula of the superficialis was found in 6 of the 34 fingers
studied. In this finger, almost all long vincula of the superficialis
originated from the ulnar side of the finger (ulnar type), and 23
of the 32 ulnar-types long vincula consisted of the broad
mesotendon and were fused to the short vinculum of the
superficialis (Fig. 8).
The special combination of the absent type of both the
profundus and superficialis was found in three fingers. However,
this combination was not found in either the index or little
finger.
Figure 9 illustrates the typical patterns of the vincular
system in each of the four fingers.

is

FIG. 8. Ulnar type of the long vinculum of the superficialis was often
broad and fused to the short vinculum in little finger.
VINCULA IN NO-MAN’S LAND 47

vat tM te
Index Finger Ring
VIP
Finger
Mi
VLP:Middle Type

Long Finger
VLP: Middle Type VLP: Mixed Type
VLS: Radial Type VLS: Absent

VLP: Middle & Proximal Types Little ners

VLS:Radiaf & Ulnar Types VLP: Middle Type
VLS:Uinar Type(broad)

FIG. 9. These schemes show the typical patterns of the vincular system in
each finger.

Discussion

The vascular supply of the flexor tendons in the digital

canal is believed to be provided segmentally through the
vincular system. Many publications have described this vincular
system and stressed its importance as the major blood supply
for the flexor tendons [2-9]. However, no publication as yet
has given a detailed description of the fine anatomy of these
systems. In this paper, 130 human fingers were analyzed, and
the long vincula of the profundus were classified into five types
into
and the long vincula of the superficialis were classified
1). The different combinati ons of these
three types (Table
has been
vincular systems in each of the four fingers studied
the intimate relationsh ip in vascular
discussed, as well as
long vincula of the profundus and the
anatomy between the
vincula of the superficial is tendon. The
short vincula or long
types of long vincula of the profundus
middle and mixed
of the
received their blood supply from the short vinculum
blood supply to the proximal- type long
superficialis, and the
48 N. OCHIAI ET AL

Table 1. Results of the Dissection

VLP VLS Index Long Ring Little

Absent 0 eZ 1 2
R 2 5 0 0
:
Mie U 0 0 0 12
R+U 7 Z, 0 6

Mid R 1 D 2 0
+ U 1 0 1 7
Prox JR se U) 5 5 5 4

Mid + Mix Absent 1 3 6 0

Mix Absent 0 D, 6 0

R 2 3} 2 0
Prox U 0 2 0 w
IR ae 1) 0 1 1 0

; : U 1 0 0 0
DEES Absent 1 1 0 0
Dist Absent 1 0 0 0

Absent U 0 1 0 1

Absent Absent 0 3 3 0

Other 1 1 3 0

Total 33 33 30 34

R: Radial type U: Ulnar type

vinculum of the profundus came mainly from the long vinculum

of the superficialis.
Patterns of vincular distribution found in this study are
possibly related to certain known hand problems. More research
is necessary to establish these previously unreported correla-
tions. For example, there is a high incidence of rupture of the
profundus tendon, particularly in the ring but also in the long
finger. This study shows that the long vinculum to the
superficialis is often absent in the ring and long fingers, and that
a fair percentage of these fingers lacked all vincula of the
profundus tendon. Since the vinculum acts as a check ligament
VINCULA IN NO-MAN’S LAND 49

in some respects, patterns of tendon rupture in certain stress

situations should be compared with vincular distribution.
Another example is the problem of flexion contracture in the
fifth finger, the most common congenital anomaly. This study
showed that long vincula of the superficialis are quite com-
monly connected on the ulnar side of the fifth finger by long,
broad mesotendon systems. The surgeon should consider this
finding in his approach to the problem, since contracture of this
structure could produce a flexion deformity.
In the future, it will be important that the surgeon analyze
finger injuries in terms of injury location as related to tendon
blood supply, rather than by concepts such as ‘‘no-man’s land”
or skin laceration. Segmental adhesion and tendon rupture can
be explained by segmental losses of nutrition and tendon
infarction” We now suggest that prior to primary repair the
surgeon release the tourniquet and observe tendon blood supply
under magnification. Prediction of poor or delayed healing may
become quite feasible with experience. This prospect suggests
new treatment concepts, such as the use of a first-stage tendon
spacer instead of repair in borderline situations. Studies are
under way to further elucidate the clinical significance of these
anatomical findings.

References

1. Edward, E.A.: Organization of the small arteries of the hand and digits.
Am. J. Surg. 99:837-846, 1960.
of
2. Brockis, J.G.: The blood supply of the flexor and extensor tendons
the fingers in man. J. Bone Joint Surg. 35B:131-138, 1953.
Surgeons
3. Caplan, H.S. et al: In American Academy of Orthopaedic
Mosby
Symposium on Tendon Surgery in the Hand. St. Louis:C. V.
Co., 1975, pp. 48-58.
4. Goss, C.M.: Gray’s Anatomy. Philadelphia:Lea and Febiger, 1973, pp.
464-465.
1-1198, 1974.
5. Leffert, R.D.: The vincula. J. Bone Joint Surg. 56A:119
tendons within
6. Lundborg, G. et al: The vascularization of human flexor
al aspects. J.
the digital synovial sheath region — Structural and function
Hand Surg. 2:417-427, 1977.
transplantation. Surg.
7. Mayer, L.: The physiological method of tendon
Gynecol. Obstet. 22:182- 197, 1916.
in normal tendons and
8. Peacock, E.E.: A study of the circulation
healing grafts. Ann. Surg. 149:415-428, 1959.
J. Surg. 109:272-276,
9. Smith, J.W.: Blood supply of tendons. Am.
1965.
50 N. OCHIAI ET AL

Bibliography
Leinert, H.E. et al: In American Academy of Orthopaedic Surgeons
Symposium on Tendon Surgery in the Hand. St. Louis:C. V. Mosby
ComelOOmpDalalosa Zs
Verdan, C.E.: In American Academy of Orthopaedic Surgeons Symposium
on Tendon Surgery in the Hand. St. Louis:C. V. Mosby Co., 1975, pp.
6-13.
Verdan, C.E.: Primary repair of the flexor tendons. J. Bone Joint Surg.
42A:647-657, 1960.

Self-Evaluation Quiz

1. The vincula are folds of the mesotendon.

a) True
b) False
2. Long vincula were found in all dissected fingers in this
study.
a) True
b) False
3. ____-—so—are ~considered to be major channels of the
segmental blood supply to the flexor tendons.
a) Short vincula
b) Long vincula
c) Neither
4. Which of the following classifications for long vincula in the
profundus can be described as rare?
a) Distal
b) Middle
c) Mixed
d) Proximal
e) Absent
5. The most common type of long vinculum is:
a) Distal
b) Middle
c) Mixed
d) Proximal
e) Absent
6. The special combination of the absent types of both the
profundus and superficialis was not found in:
a) Index |
b) Long
VINCULA IN NO-MAN’S LAND 51

c) Ring
d) Little
7. Patterns of vincular distribution are probably related to
particular hand problems.
a) True
b) False
8. Contracture of the long vincula of the fifth finger (sur-
gically) may produce:
a) Tendon rupture
b) Flexion deformity
c) Segmental adhesion

Answers on page 527.

 1, Cee. ol dee (ete, coe we nas lup leet
piri
ae: 16, “nd AF
be ds) PS
Cs eek ieee +
 The Intact Sublimis

Edward A. Nalebuff, M.D.

Objective

This paper presents the various surgical procedures for

patients with an intact sublimis tendon, emphasizing those
factors to be considered before choosing the most appropri-
ate approach for improving function with minimal risk.
s

The restoration of active digital flexion in patients who have

injured both flexor tendons is one of the most perplexing
problems of hand surgery. It is a problem that is not yet fully
solved. The difficulty in achieving full mobility following flexor
tendon repairs within the digital sheath is well recognized.
However, one aspect of flexor tendon surgery which deserves
separate consideration is the treatment of those patients who
have lost the profundus action but have an intact sublimis.
These patients differ in several important ways from patients
less, the
who have had both tendons cut: the functional loss is
subtle. Because of
prognosis is better, and the diagnosis is more
profundus
the anatomical relationship of the flexor digitorum
to an ex-
to the other flexor tendons, it becomes vulnerable
middle phalanx
ternal wound over the distal portion of the
the superficial flexor.
where it passes through the bifurcation of
be divided without an
It is from this point distally that it can
isolated damage of the
injury to the superficial flexor. However,
ways. For ex-
flexor digitorum profundus can occur in other
flexor can result from an
ample, an isolated rupture of the deep

l Professor of Orthopedic
Edward A. Nalebuff, M.D., Associate Clinica
d Medica l School ; Chief, Hand Service , Robert B. Brigham
Surgery, Harvar
Englan d Baptis t Hospit al, Beth Israel
Hospital; Orthopedic Staff, New
Peter Bent Brigh am Hospit al, Boston , Mass.
Hospital and
n, C. (ed.): Tendon Surgery of
Reprinted, with permission, from Verda
stone, Edinburgh-London-New York.
the Hand. © 1979, Churchill Living
ifique Francaise, Paris.
Original copyright, Expansion Scient
53
54 E. A. NALEBUFF

excessive strain applied to its terminal attachment. Certain

disease processes such as rheumatoid arthritis can weaken its
substance and cause spontaneous rupture by attrition either at
the wrist or within the palm.
In this chapter I shall discuss our approach with patients
who have an intact sublimis, an approach that minimizes the
risk of further impairment of digital function and is usually
successful in improving the remaining function. Many forms of
treatment have been advocated for patients with an intact
sublimis. These include primary or secondary repair or advance-
ment, fusions, tenodesis and even the insertion of flexor tendon
grafts. Little wonder that confusion exists regarding the proper
management of this condition. I shall try to clarify the situation
by describing our indications for each surgical procedure.

Diagnosis

The diagnosis of a flexor digitorum profundus rupture is

often missed initially. With the presence of an intact, fully
functioning sublimis, the remaining digital function is good.
When one compares this to the circumstances of a traumatic
rupture, it is easy to understand how this occurs. For example,
a typical patient may be a football player who injured his finger
attempting a tackle. The momentary discomfort is shrugged off
by both the player and the trainer as a sprain. Usually, he
continues to play and it is only later that the loss of distal joint
flexion is noted. Another example is the patient with rheuma-
toid arthritis who lives with intermittent or constant dis-
comfort. The slight alteration in digital flexion is first looked
upon as a temporary nuisance. A complete evaluation and
diagnosis may not be made until the hand is examined as a
result of other, more significant changes. Another example is
patients with small lacerations on the volar aspect of the finger,
who are usually given a cursory examination to determine the
presence of sensation and the ability to flex the finger. The loss
of profundus action is overlooked in the excitement of the
injury and the emergency care. Later, the patient notices a lack
or weakness of terminal flexion and reexamination by a more
experienced doctor clarifies the diagnosis.
Actually, the diagnosis of the isolated profundus lesion
should be easy. It requires suspicion or awareness plus a
THE INTACT SUBLIMIS DOD

thorough clinical examination. As a general rule, one may

assume that all longitudinal structures passing the site of lacera-
tion are divided until proven otherwise. With this in mind one is
unlikely to overlook the divided flexor digitorum profundus. It
is not necessary to inspect the depth of the wound in order to
make the diagnosis. An altered digital posture should alert the
examiner. The distal joint of the involved finger stays in less
flexion than the adjacent digits. An individual testing of the
range and strength of active flexion of the terminal joint should
confirm the diagnosis. Once the diagnosis has been made, either
initially in the emergency ward or at some later date, one must
then further evaluate the situation. Three factors that need to
be determined are:
1. The level of tendon injury.
2. The degree of tendon retraction.
3. The functional capacity of the remaining superficial
flexor.
Certainly the patient’s age and occupation as well as the
over-all functional loss should also be considered. All else being
equal, the three aforementioned factors are the most useful in
determining the proper treatment for each individual case.
The level of skin laceration does not necessarily indicate the
level of tendon division. This relationship depends upon the
position of the finger at the time of injury. If the digit was in
acute flexion, then the cut tendon will be distal to the skin
injury. For example, the patient might have a skin laceration
be
over the proximal phalanx; yet the tendon division could
beyond the sublimis bifurcation in an area where repair could
cut
be considered. The reverse, of course, it true. A distal skin
extension ,
over the middle phalanx might have occurred in
within the
leaving the cut flexor tendon ends more proximal
flexor tendon sheath deep to the superficial flexor.
is that
A factor closely related to the level of tendon injury
the vincul um,
of tendon retraction. If the laceration is distal to
betwee n the
the tendon may not retract significantly. The gap
ts at spon-
cut tendon and distal attachment is small. Attemp
may restore some limited active motion to the
taneous healing
making a diagnos is
distal joint, which adds to the difficulty of
in keepin g the
in a late case. The vincula are particularly helpful
profun dus within the digit in a tramatic
flexor digitorum
56 E. A. NALEBUFF

tendon rupture. Sometimes x-rays are helpful when a small

bone fragment is pulled off the distal phalanx and can be seen
in the soft tissues over the middle phalanx. With division more
proximal, the tendon retracts into the tendon sheath over the
proximal phalanx or into the palm where it adheres to the
surrounding structures. These adhesions may cause a teno-
synovitis and adhesions which subsequently reduce sublimis
function. The location of the proximal tendon is an important
fact in determining the proper treatment. Palpation of the digit
is helpful in making this determination. The lack of fullness
distally in the presence of a tender swelling in the palm
indicates proximal retraction. In this position the tendon thick-
ens and ultimately shortens, making attempts at later repair or
advancement futile.
The most significant function to determine as part of the
evaluation is the extent of the remaining superficial flexor
function. Ideally, the sublimis should be functioning normally.
In those patients who have normal digital extension as well as
flexion of the finger to the palm, the functional loss may be
slight. The need for treatment then depends upon the patient’s
occupation, age and which digit is involved. A patient who has
some terminal joint stability might not require any treatment.
In this situation a diagnosis and explanation to the patient
usually are all that is necessary. In other patients with signifi-
cant functional loss, surgery should be undertaken to improve
over-all digital function.

Treatment

Although the operative procedures advocated for this con-

dition are many, and the timing of treatment is controversial,
there are esssentially only three main objectives regardless
which surgical procedure is chosen. These are:
1. To restore the profundus.
2. To provide terminal stability.
3. To improve over-all digital flexion.
The choice of surgical procedure depends upon the factors
previously discussed (level of tendon injury, degree of tendon
retraction and extent of superficial flexor function). Diverse
surgical approaches such as tendon repairs, advancement,
THE INTACT SUBLIMIS 57

tenodesis, flexor tendon grafts and flexor tenolysis should be

considered in the light of these many factors in order to obtain
a rational approach to treatment.

Restore Pre-existing Profundus

The first group of operations I will discuss attempt to
restore the pre-existing flexor digitorum profundus, by tendon
advancement or repair. This approach is only indicated in distal
lesions. These patients typically have good superficial flexor
function. This approach of repair or advancement of the flexor
digitorum profundus is not indicated in proximal lesions. In this
situation it is best to close the skin and provide terminal joint
stability at a later date. Tendon repair or advancement can, of
course, be carried out either primarily or at a later stage. If a
patient is seen within a few hours of injury and the proper
diagnosis is made of either a traumatic rupture or a very distal
laceration, the best treatment is tendon advancement. In this
technique the tendon end is reattached to the base of the distal
phalanx with a pull-out wire. The suture line is therefore
brought beyond the terminal joint, minimizing the risk of
restricted terminal flexion. Again, by bringing the suture line
distally, one minimizes the risk of interfering with the super-
ficial flexor. If wound conditions are good, the primary ap-
proach is indicated. However, this procedure can be done
several weeks or several months later with an excellent progno-
sis if the tendon has not retracted proximally (Fig. 1). This may
be determined by clinical palpation. Complications of flexor
tendon advancement result from carrying out the advancement
over too great a distance. This is not a problem in spontaneous
the
tendon ruptures in which no length is actually lost. If
is carried out more than 0.5 cm, the patient may
advancement
If this
develop a flexion contracture of the terminal joint.
necessary to release the flexor tendon unless the
occurs, it is not
is to
adjacent fingers have been affected. All that is necessary
(Fig. 2).
arthrodese the distal joint in a less flexed position
carried out
Tendon repair, either primary or secondary, can be
lesion, but
in those patients who have a more proximal tendon
These cases
one that is still beyond the superficial bifurcation.
that the tendon
are usually done late because the diagnosis
clinically and, in
lesion is distal enough may not be obvious
FIG. 1. An example of secondary advancement of the flexor digitorum
profundus. (A) Note the healed distal laceration of the index finger. (B)
The patient has excellent sublimis function but lacks terminal joint flex-
ion. (C) Appearance of tendon at surgery. (D) Advancement performed
with pull-out wire technique. (E, F) Shows postoperative function with
restoration of terminal joint flexion.
 (A) Note flexion con-
FIG. 2. A complication of primary advancement.
distal joint of the ring finger. (B) Distal joint deformity
tracture of
full sublimis function.
corrected by fusion. (C) Patient demonstrates
60 E. A. NALEBUFF

fact, may not be discovered until surgery. With this technique,

one exposes the tendon sheath over the middle phalanx. The
deep flexor is often found adherent at this point and can be
freed from surrounding tissues. With excision of the surround-
ing tendon sheath it is then possible to carry out an end-to-end
repair using very fine suture material. Tension is taken off the
repair with a transfixing wire using the Verdan technique (Fig.
3). The most significant feature in this repair is that it is carried
out beyond the proximal interphalangeal joint so that sublimis
function is not compromised. If one carries out a secondary
repair over the middle phalanx and the tendon becomes adher-
ent at this point, one has essentially provided a tenodesis with
stability of the terminal joint.

Provide Distal Joint Stability

The second approach in the management of these injuries
provides joint stability by fusion or tenodesis. These procedures
do not increase finger flexion and are, therefore, not indicated
as the sole consideration for those patients who have only fair
superficial flexor function. If there is no doubt about the
proximal level of tendon injury and the patient has maintained
good sublimis function, one can proceed to fusion via a dorsal
approach without any volar surgery (Fig. 4). However, if there
is some doubt as to the level of deep flexor, one can carry out
an exploration over the middle phalanx. If the lesion is found to
be proximal, then it is possible to carry out a tenodesis with the
terminal tendon stump, suturing it either to the middle phalanx
or to the flexor tendon sheath. In order to protect the tenodesis
a Kirschner wire should be passed across the distal joint for six
weeks. It should be emphasized that fusion or tenodesis is not
indicated unless the patient has good sublimis function.

Improvement of Digital Flexion

Those patients who have cut the deep flexors and have
limited superficial flexor function require the third approach:
an improvement of over-all active digital flexion. Fusion or
tenodesis to stabilize the distal joint is not enough when the
patient cannot flex the finger close to the palm. There are
basically two ways to improve active digital flexion. One is by
the insertion of a free flexor tendon graft through the intact
THE INTACT SUBLIMIS 61

e
flexor digitorum profundus
FIG. 3. An example of secondary repair of the
lacerat ion at the base of the
using the Verdan technique. (A) Note healed
index finger. (B) Patient demonst rates full proximal
middle phalanx of the
joint flexion. (C) Appearance
interphalangeal joint flexion, but lacks distal
tendon found adheren t over the middle phalanx.
at surgery. Deep flexor the
xing pin. (E, F) Shows
(D) Shows tendon repair. Note proximal transfi
flexion and extensi on.
patient’s postoperative
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SUBLIMIS
THE INTACT
64 E. A. NALEBUFF

FIG. 6. The use of tenolysis to improve digital motion. (A, B) This patient
has only partial sublimis function which is not sufficient to flex the ring
finger to palm. (C) Shows profundus tendon being removed from the
palm. (D) Appearance of sublimis tendon following tenolysis and removal
of profundus. (E, F) Shows improved postoperative function. Note fusions
of distal joint.
THE INTACT SUBLIMIS 65

d
FIG. 7. The use of tenolysis and transfer in a patient with intact sublimis
in the small finger. (A) Patient has weak, insufficient digital flexion. (B)
to the
Note intact sublimis and short deep flexor which was sutured
sublimis in the palm. (C, D) Improved postoperati ve function shown.
Distal joint fused to provide stability.
flexor
sublimis and the other is by removal of the adherent deep
to restore its normal
with tenolysis of the superficial flexor
many;
exursion. Flexor tendon grafts have been advocated by
sublimi s is never indicate d.
all agree that removal of an intact
profund us functio n with
Those surgeons who attempt to restore
usually take
a tendon graft try not to disturb the sublimis. They
of choice. The technique
the thin plantaris tendon as the graft
has been adequat ely de-
of inserting the flexor tendon graft
GG E. A. NALEBUFF

scribed elsewhere and therefore will not be repeated here.

However, special risks are involved especially when sublimis
function is already good. In this situation one risks losing
over-all digital motion to grain active control of the distal joint
(Fig. 5). This is a risk not to be taken lightly. For this reason, I
prefer to restore superficial flexor tendon function and stabilize
the distal joint. A volar zig-zag incision is made in the distal
palm. The profundus tendon is usually found to be shortened
and adherent to the sublimis tendon and tendon sheath. It is
separated and divided near the lumbrical attachment. Traction
on the superficial flexor should fully flex the proximal inter-
phalangeal joint. If this does not occur, the incision is carried
distally and a more extensive tenolysis performed. Once trac-
tion on the superficial flexor achieves full flexion, attention
should be directed to the distal joint if additional stability is
needed. An example of tenolysis and fusion is shown in Figure
6. This approach usually restores good digital motion with
satisfactory strength, except in the small finger where the sub-
limis may be quite small and weak. Faced with an intact but
weak sublimis, we suture the profundus tendon to the super-
ficial flexor in the palm to add its strength in flexion (Fig. 7).

Self-Evaluation Quiz

1. An experienced physician should diagnose a divided flexor

digitorum profundus by:
a) Inspection of the depth of the wound
b) X-ray examination
c) Altered digital posture
2. The three most important factors in determining treatment
of a divided profundus are:
a) Over-all functional loss
b) Degree of tendon retraction
c) Age
d) Level of tendon injury
e) Functional capacity of superficial flexor
f) Patient’s occupation
3. The level of skin laceration does not necessarily indicate the
level of tendon repair.
a) True
b) False
 67
THE INTACT SUBLIMIS

indicated in:
4. Tendon advancement or repair is only
a) Distal lesions
b) Proximal lesions
of more than 0.5 cm is likely to
Tendon advancement
cause:
a) Compromised sublimis function
b) Restricted terminal flexion
joint
c) Flexion contracture of terminal
the patient with poor
Fusion or tenodesis is indicated for
sublimis function.
a) True
b) False
flexion is usually best
Improvement of over-all digital
achjeved by:
a) Fusion
b) Tenodesis
c) Flexor tendon grafts
d) Tenolysis and fusion

Answers on page 527.

 Extensor Tendon Injuries
Grady S. Clinkscales, Jr., M.D.

Objectives
extensor
1. To point out the differences between
and flexo r tendo n injuri es.
and secondary
2. To give indications for primary
tenorraphies.
repair.
3 To illustrate methods of tendon
ify chara cteri stics of tendon lacera-
4. To ident
from zones 1 through 4.
tions at various levels

of lacerations of extensor ten-

Generally speaking, repair
or tendons because the extensor
dons is much easier than of flex laid
loose paratenon, and are over
tendons are surrounded by Thes e fact ors
subcutaneous tissues.
with more mobile skin and repa ir. Most
more easily following
allow the tendon to glide arily,
tend ons can be carried out prim
lacerations of extensor must be a clean
met. The wound
provided certain criteria are can be adeq uate ly
tissue, and one that
one, with minimal loss of less than six hour s,
should be short,
debrided. The time interval to assis t in the
should be available
and adequate personnel joined by
inju ry, the tendon ends can be
repair. For an acute and the repa ir pro-
mattress sutures
interrupted, nonabsorbable an inte rnal splin t, a
nt. Frequently,
tected by an external spli est joint. If
is also advisable at the near
smooth Kirschner wire, rnal fixation is
open reduction with inte
fractures are present, an fixation allows
that time. The internal
usually carried out at and facili-
during the healing process,
stability of the fracture but of the
not only of the joints
tates early mobilization
repaired tendon.
Hand
Surgeon, Consultant,
dy S. Clin ksca les, Jr., M.D., Orthopedic
Gra Ga.
al Hospital, Atlanta,
Surgery, Grady Memori

69
70 G. S. CLINKSCALES

Secondary tendon repairs are carried out whenever a pri-

mary repair is impractical due to loss of overlying skin coverage;
severe contamination is present; or there has been damage to
other structures such as adjacent nerves, vessels or the underly-
ing skeleton. For a secondary repair to be successful, again
certain criteria must be met. Skin coverage should be adequate,
loose and pliable enough to allow the repaired tendon to func-
tion. Fractures should be healed and joints have a functional
range of motion. Sensation should be present or restorable.
Repairs of tendons may be carried out by direct suture, by
filling gaps with a tendon graft or by tendon transfers. Consider
the extensor surface of the hand being divided into five zones.
Zone 1 is that area that involves the terminal portion of the
extensor tendon at its insertion. Zone 2 involves the extensor
tendon at the level of the proximal interphalangeal joint and
proximal phalanx. Zone 3 is that area over the dorsum of the
hand from the metacarpophalangeal joint to the extensor
retinaculum of the wrist. Zone 4 involves the area of the wrist
at the level of the extensor retinaculum, and zone 5 involves
that area proximally. The most common areas of injury are in
the first two zones.
A laceration or avulsion of the extensor tendon at or near
its insertion on the dorsal lip of the proximal phalanx results in
a typical mallet deformity. When a laceration is transverse and
clean, the tendon can be resutured and the distal joint splinted
in full extension with a small, single, smooth Kirschner wire.
When the tendon has been avulsed and there is not enough
stump distally for suture anchorage, then the tendon must be
anchored to bone (Fig. 1). Two small drill holes are made on
the dorsal lip of the distal phalanx, 3 mm from midline, with
each drill hole converging toward one another subcortically. A
suture is passed through the radial corner of the proximal
portion of the lacerated tendon. The needle is then tunneled
from one drill hole through the other, and the suture is passed
through the ulnar corner of the laceraled tendon. From this
point, the suture is passed back through the two drilled holes in
the reverse direction, thence again through the radial corner of
the lacerated tendon near the point the suture began. Thus the
tendon has a mattress suture through both corners of the
lacerated tendon. By snugging and tying the suture, the tendon
 TENDON INJURIES Wal
EXTENSOR

its insertion.
an avulsed extensor tendon from
FIG. 1. Method of suture of of the base of the distal
in the dorsal cortex
(A) Two drill holes are made corne r of the avuls ed tendon.
ed through one
phalanx, and a suture is pass (C) The sutur e is then
through the drill holes.
(B) The suture is tunneled avuls ed tend on, and (D) back
corner of the
passed through the other re is then comp leted
. (E) The mattress sutu
through the same drill holes on back to bone at its original
the torn tend
and (F) tied. This snugs
insertion.
 aD G. S. CLINKSCALES

is coapted to bone and securely anchored. A single Kirschner

wire transfixes the joint in neutral extension to relieve tension
on the site of juncture (Fig. 2).
With a closed avulsion type of injury, when treated within
the first week, the avulsed extensor tendon may simply be
treated by internal or by external splinting alone, without
having to expose the tendon for a formal repair. Splinting is
continued for five to six weeks.
Fresh lacerations over the dorsum of the middle phalanx are
treated by direct suture and splinting in extension for three
weeks.
In zone 2, lacerations at the level of the proximal phalanx
may involve only one of the lateral bands. These can usually be
sutured with two or three interrupted, nonabsorbable mattress
sutures and the digit splinted in slight flexion for about two
weeks, if the opposite lateral band is still intact. More fre-
quently, however, the laceration involves the central slip at its
insertion on the dorsal lip of the middle phalanx. It is absolute-
ly essential that this portion of the tendon be repaired. If not,
the proximal stump of the central slip retracts, allowing the
proximal interphalangeal joint to droop into a slightly flexed
position. This sets off a chain of events which allows volar
migration of the lateral bands, which in their normal position
act as extensors for the interphalangeal joints. When the lateral
bands sublux volarward, they become flexors, contributing
to
the deformity. If allowed to persist, a fixed flexion contractu
re
of the proximal IP joint occurs and contraction of the oblique
retinacular ligaments develops, causing a fixed hyperextension
deformity at the distal joint. Collateral ligaments at
the proxi-
mal interphalangeal joints then contract, and
the typical
troublesome, chronic boutonniére deformity is obvious.
Most
boutonniére deformities are the late sequelae of a central
slip
injury that has gone either unrecognized or untreated
. At
surgery, the central slip must be identified and
freed of its
adhesions, and the lateral bands dissected free along
their volar
margins. This dissection will allow the lateral bands
to be
relocated to their more normal position on the dorsum
of the
middle phalanx and the proximal interphalangeal
joint, and
they are resutured to the central slip which is advanced
to its
normal point of insertion in a manner similar to that
described
for the mallet finger.
EXTENSOR TENDON INJURIES US

eee
LT

DEL

ei
sa

ae
.

<

laceration has occurred

lacerations. (A, B) The
FIG. 2. Extensor tendon on has been repaired and
dista ] joint. (C) Th e tend
over the dorsum of the . (D) A .035 Kirschner wire
on back to bone
the suture snugs the tend pl acement of the tied
in 5 ° hyperextension. The
transfixes the distal joint
metallic suture can be seen.
 74 G. S. CLINKSCALES

The radial-most fibers of the lateral band are preserved as an

extension of the lumbrical muscle and the oblique retinacular
ligament, to allow active extension of the distal joint post-
operatively. A Kirschner wire is passed obliquely across the
joint to hold it in full extension for three weeks. A series of
graduated exercises is begun, with dynamic splints to facilitate
alternate periods of time in extension and in flexion. It is
difficult to regain full extension and full flexion for a proximal
interphalangeal joint when the boutonniére deformity has been
of long standing. When involvement of an extensor tendon at
the proximal or distal interphalangeal joint is associated with
tendon loss and joint damage, then a fusion of the joint is
usually the best alternative. For the distal joint, a fusion is done
with 10° to 20° of flexion, and at the proximal interphalangeal
joint, the position is in 40° to 50° of flexion.
Lacerations of extensor tendons within zone 3 are probably
the easiest to diagnose and to treat. On active extension of the
fingers, there is an extensor lag at the metacarpophalangeal
level, usually of no more than 40°. The lag may even be much
less, depending on the checkreining effect of the juncturae
tindinae. While the proximal end of the divided tendon retracts
somewhat, usually a simple extension of the laceration can be
made to retrieve the tendon, which is sutured with interrupted
mattress sutures (Fig. 3). It is not necessary to transfix the MP
joint with Kirschner wires except in unusual situations, but
a
cast is applied to hold the wrist in slight dorsiflexion and the
involved digit in full extension at the MP joint for approxi-
mately four weeks. A Boehler splint attached to a short
arm
cast is an effective way of immobilizing only the involved
digit.
When extensor tendon damage involves a gap, then
the
repair may require a tendon graft to span the defect,
or a
side-to-side juncture of the lacerated tendon against
its adjacent
communis tendon. If the gap is extensive, and if
there are
multiple tendons involved in the presence of an intact
extensor
indicis proprius tendon, then this tendon may
be detached
distally and used as a transfer.
The extensor pollicis longus tendon attaches to the
thumb
distal phalanx, and assists in extension of the thumb
distal joint
and metacarpophalangeal joint. When this tendon
is lacerated
within zone 38, an extensor lag usually occurs
at the meta-
EXTENSOR TENDON INJURIES 15

the fourth
tendon can be seen overlying
FIG. 3. The severed extensor tend on has been repaired
B) The exten sor
metacarpophalangeal joint. (A, of full flexion and
sutures. (C, D) Note return
with interrupted mattress on lacer ation s at this level.
expe cted from tend
extension, which is usually
 76 G. S. CLINKSCALES

carpophalangeal joint, but frequently not at the distal joint

since the intrinsic muscles supply independent distal joint
extension. On testing distal joint extension strength, however, it
can usually be determined that it is weaker than on the
undamaged side. When seen fresh or early after division of the
extensor pollicis longus, the tendon can usually be retrieved.
The proximal stump frequently retracts, and if it is beyond
reach at Lister’s tubercle, then the tendon can be rerouted and
bypass the tubercle to overcome some retraction of the tendon
(Fig. 4). If this gap still cannot be overcome, then a tendon
graft can be used. Preferentially, the extensor indicis proprius
tendon is used as a transfer rather than a graft.
At zone 4, extensor tendon lacerations can be treated in the
ways mentioned for zone 3. It must be recognized, however,
that this zone is the area of the dorsal compartment tendon
sheaths, the tight fibro-osseous canals which have such little
tolerance for scar tissue or enlargement of tendons from scar-

FIG. 4. (A) Laceration of a right extensor pollicis longus

tendon. The
severed tendon ends are identified by the hemostat.
(B) The extensor
tendon has been rerouted so that it short-cuts the turn
around Lister’s
tubercle.
EXTENSOR TENDON INJURIES eeu

ring. It is therefore necessary to compromise the sheath by

freeing the tendon from its sheath and allowing it to lie un-
roofed. Whenever possible, a portion of the compartment
sheath is left intact either proximally or distally to prevent
bow-stringing. At times, a tendon pulley may need to be created
either proximally or distally as a preventative measure. If severe
damage to the extensor tendons has occurred, tendon transfers
are usually necessary using the flexor carpi ulnaris rerouted
around the ulnar border of the distal forearm, sometimes ex-
tended with a graft.

Summary

Lacerations and injuries to extensor tendons are generally

of the
easier te treat than similar injuries on the flexor side
zed
hand and wrist. Extensor tendon injuries can be categori
and
into five zones. In zone 1, mallet finger deformities occur,
importa nt to
in zone 2, boutonniére deformities develop. It is
the extenso r
reconstitute insertion of the terminal end of
at these two
tendon and the central slip of the extensor tendon
deformities are
joints to prevent these deformities. Boutonniére
more difficult.
usually seen in the chronic stage, making repairs
in zone 3, are usually
Lacerations over the dorsum of the hand,
return of function.
the easiest to repair with the most normal
tment tendon
Lacerations at zone 4 within the dorsal compar
may need to be
sheaths are more troublesome, and pulleys
reconstructed.

Self-Evaluation Quiz

tendons can be repaired either pri-

1. Laceration of extensor
marily or secondarily.
aye rue
b) False
of a digit can best be done
2. Tendon repairs at the distal joint
to bone.
by attaching the divided tendon end
a)urrrue
b) False
mechanism at the inter-
3. With a laceration of the extensor
fic repair of the central slip is
phalangeal joint level, the speci
relatively unimportant.
78 G. S. CLINKSCALES

a) True
b) False
A laceration of an extensor tendon on the dorsum of the
hand generally has a good prognosis.
a) True
b) False
When the extensor pollicis longus tendon has been severed,
a droop at the distal joint always occurs.
a) True
b) False
One method of repair of a retracted extensor pollicis longus
tendon is by rerouting at Lister’s tubercle.
a) True
b) False
The flexor carpi ulnaris is the tendon of choice for repair of
an extensor pollicis longus tendon gap.
a) True
b) False

Answers on page 527,

 Penetrating Wounds: Initial Care
and Management
Joseph A. Arminio, M.D.

Objective

The purpose of this paper is to emphasize awareness of

the potential hazards when a wound appears to be simple.
Gredence should be given to the mechanism of the injury
deeper
and the correlation of the surface wound to the
nt,
structures that may be involved. Following this assessme
and the initial care, which may be the
debridement
definitive care, should be executed.

be obtained from
In all types of wounds, a history should
to docum ent how, when
the patient or a reliable source in order
is impor tant if one is to
and where the wound occurred. Timing
bacter ia begin to
work within the golden period before
hours. Knowi ng the
multiply; this means the initial six to eight
l so that admini stra-
kind of contaminant in the wound is helpfu n
initia ted under certai
tion of the proper antibiotic can be
treat ment, the wound
circumstances. At the time of the initial
the ultimate aim of a
can be left open and staged to attain
healed, functioning part.
is one characteristic
Debridement is most essential and
basic step of underlying
method of treatment that is a
minimized and should be
importance; it should not be
ughly. Unde r many circum-
performed adequately and thoro
enlarged for adeq uate initial
stances, the wound must be
treatment.
the part of the hand involved
Knowledge of the anatomy of ,
of repair should be kept in mind
is also essential. The principles at the time of
should be appl ied
and then the proper principles i a
eae ee
on, Del.
te Practice in Surgery, Wilmingt
Joseph A. Arminio, M.D., Priva

fie)
80 J. A. ARMINIO

the care of the wound. The anatomy of the hand should be well
understood, both topographic anatomy and the anatomy of the
deeper structures, so that serious thought and understanding
can be given to the deeper structures that could be involved by
the penetrating wound.
Many of these wounds are seen early in the emergency room
or in the practitioner’s office, and this initial care can be
definitive care if it is performed competently and compre-
hensively. In this way, secondary procedures can be minimized;
and the ultimate result of return of function and minimized loss
of time can be hastened satisfactorily.
The initial examination should be recorded accurately and
thoroughly; all of the findings should be enumerated, including
the negative findings which may help a succeeding physician or
oneself in following the patient through the normal sequence of
healing. Inspection of the wound should be followed by active
and passive movements. Many times, the stance of the hand can
alert one to the underlying problem by the manner in which the
fingers are held or how they move. Testing for nerve supply is a
must, because if this has not been done and a nerve deficit
becomes apparent later with healing of the wound, the question
will arise as to whether this was present initially or was
iatrogenicly introduced during treatment.
The anatomy of the hand, some of the principles of repair,
and the measurements that must be taken and documented are
presented in detail elsewhere in this volume. The following case
reports and discussion illustrate some of the hazards, strengths
and weaknesses of actual care given in the initial management of
several types of penetrating wounds.

Case Reports

Stabbings
Case 1. A stabbing wound over the dorsal radial surface
in the proximal third of the forearm was inflicted by a
knife. When initially seen in the emergency room, the
wound was cleansed and sutured after a cursory examina-
tion. One week later, the patient brought to the examiner’s
attention that the dorsum of the thumb and hand was
numb. On examination, the sutured wound appeared to be
clean, with an ecchymotic area about the forearm. There
PENETRATING WOUNDS 81

was no documentation as to whether the nerves distally

had been found to be intact or whether there had been an
injury to the superficial radial nerve, the terminal cutane-
ous branch of the radial nerve which lies deep to the
brachioradialis muscle before becoming superficial. Two
questions were raised: had this nerve been transected or
was there a hematoma in the wound causing secondary
pressure on the nerve and resulting in the numbness and
the discomfort distally in the hand? The patient’s ques-
tions could not be answered at that time because of the
lack of documentation of the initial examination in the
emergency ward. As the patient was followed over a period
of six weeks, some return of the nerve function became
evident; and then there was complete healing with no
the
paresthesias and with a full return of sensation during
which signified that the wound had not
next three months,
involved the nerve directly but indirectly. The patient’s
initial
concern and doubt could have been erased by the
thinking of the possible involveme nt of a
examiner’s
more thorough
deeper structure and by his carrying out a
examinati on.
not inspection
Debridement means cleansing of the wound,
means removal of all
and casual flushing out of the wound. It
nonviable tissue that
dead tissues and nonviable or potentially
cleansing to prevent
can be assessed at the time of the initial
allows tissues to heal
infection and final suppuration. It also
from undergoing undue
more rapidly and keeps the part
of motion if suppuration
fibrosis, stiffness and loss of the range le
should commence. If the wound is complex and multip
the overly ing integ ument ,
structures are involved, including not
supply, the wound does
nerves, tendons, bone and vascular
closed at the time of the initial repair. After an
have to be
determined or achieved and
adequate vascular supply has been
wound can be stabilized
after thorough debridement, the
third procedures of debride-
without closure. Second and even
over the succeeding three to
ment may have to be performed
nonviable tissue. This will
five days to remove all potentially is carried
definitive closure
further stabilize the wound before in
to execute proper debridement
out. It may take several hours of time should
necessary amoun t
a severe blast injury, but the
82 J. A. ARMINIO

be spent in performing this initial and vital step. At the time of

the debridement, salvage all possible usable tissue; this thought
should always be kept in mind. The surgeon must remember
that he is dealing with a human being and not just a piece of
anatomy that has been injured. The tissue of the hand,
particularly the distal portions of the fingers, is very specific
and unlike the skin in any other part of the body. It contains
nerve endings that are very sensitive, and this innervated skin is
not easily matched elsewhere. These portions of skin can be
used for transfer or rotation to achieve adequate coverage
during the reconstruction. In this way, an improved end result
can be achieved.
Case 2. A young woman was working on a press and
inadvertently hit the foot pedal when her hand was near a
tube that was being extruded from the machine. The tube
penetrated her hand through the distal portion of the
fourth and fifth metacarpals (Fig. 1). The traversal of the
tube through her hand interrupted the tendons and the
bony architecture. A discussion was held with the patient,
and she was advised that she could possibly lose a portion

FIG. 1. Plastic tube penetrating the ulnar side of the hand.

PENETRATING WOUNDS 83

of her hand because of the extensive nature of the wound.

Unless the emergency situation does not allow it, a
discussion with the injured person should be carried out in
a gentle manner, and the alternatives of treatment should
be outlined to the patient. The surgical procedure should
encompass not only the obvious need to take care of the
wound but also the needs of the patient, the cosmetic
appearance after healing of the part, the ambitions and
desires of the patient, and the work that the patient will be
doing after the wound has healed. In this case, it was
obvious at the time of the initial examination that there
could be a resulting loss. If reconstructive procedures were
for
to be carried out, it would a long and tedious ordeal
from a poorly
the patient, with a poor result expected
of the
functioning part. The obvious procedure at the time
of the fifth finger as
debridement was to preserve the skin
and the tissue was
a pedicle flap. The finger was filleted,
healing
used to close the wound primarily and to hasten
be considered later, but
(Fig. 2). Further surgery would
method of manageme nt for
this proved to be a satisfactory

cover
as a composite pedicle graft to
FIG, 2. Filleted fifth finger was used
the ulnar border of the hand.
84 J. A. ARMINIO

this very extensive wound, for there was a return of

nerve-innervated tissue to the ulnar side of the hand.
Biting Injuries
Bites from humans and animals are common. A bite from a
human is a potentially dangerous wound because of the mixed
organisms that are found in the mouth and can be introduced
into the wound at the time of the bite. If the bite extends down
into the joint surfaces or below the fascia into the compart-
ments of the hand, the wound should be allowed to remain
open for drainage and decompression after thorough debride-
ment. A delayed primary closure will result in no additional
loss. Bacteria remaining in the depths of a wound that has been
closed without thorough cleansing or decompression can result
in an infection or can allow growth in this anaerobic area,
resulting in abscess formation and osteomyelitis. One common
example was a patient whose fist struck against the front teeth
of another person, with the teeth penetrating the metacarpal
region on the dorsum of the hand. The metacarpal head became
involved with osteomyelitis because of early closure and
improper debridement. Injuries of this kind can result in the
loss of joint motion, tendon binding and a poorly functioning
hand.
Animal bites are usually less of a potential hazard; but again
proper cleansing and debridement are indicated. Snake and
other bites will be discussed elsewhere, but these wounds should
also be treated with thorough debridement; at times, it may be
necessary to leave the wound open for a satisfactory end result.
Proper follow-up observation of the wound is necessary
regardless of whether the wound is closed or open. The ultimate
aim of the treatment of any of these wounds is to obtain a
functioning part, as well as a functioning hand.

Objects Injected Under Pressure

Foreign material can be driven into a wound from a
stabbing or piercing of the skin; for example, fragments of lead
from a pencil, fragments of clothing overlying the site of the
wound or particles of wood can cause tattooing of the skin and
the underlying surfaces and cause abscess formation. To prevent
tattooing, if at all possible, the wound should be excised
without leaving a major defect. Inspection for any residual
PENETRATING WOUNDS 85

fragments of foreign material should be carried out. Clothing

and wood particles should be flushed out. Individuals have been
known to carry such material about for some time without
consequence and the material has later been extruded. Occas-
ionally, this material becomes encapsulated and causes problems
later due to pressure on nerves or moving parts. For example, a
youngster had a fragment from a lead pencil beneath the surface
of the palm for two years, but it finally became symptomatic
and had to be excised. Splinters should also be treated
adequately, and many times enlargement of the wound has to
be done to adequately remove the foreign material.
Case 3. The work or home site can be potentially
dangerous areas if one forgets what he is doing, as did a
baking company employee who was stapling boxes with an
automatic stapler. He turned away for a moment and his
thumb got into the path of the stapler and became stapled
t
to a box through the thumb nail (Fig. 3). After assessmen
the staple was removed, the nail and its
of the wound,
cuticle were preserved in segments (Fig. 4), and a
satisfactory end result was achieved without inflicting
further damage to the thumb (Fig. 5).

staple.
FIG. 3. Thumb was skewered by large industrial
86 J. A. ARMINIO

FIG. 4. The staple was removed, the nail was decompressed, and the
wound was debrided and closed.

FIG. 5. The end result is a functioning thumb.

PENETRATING WOUNDS 87

Looking for glass foreign bodies can be difficult because all

glass is not radiopaque. Thorough debridement and inspection is
the main guideline when treating a patient who has gone
through a pane of glass.
Case 4. An individual had his hand go through a glass
pane that he was removing; when seen two years later, he
gave a six-month history of having an uncomfortable
feeling beneath the scar across the wrist. He had pares-
thesia at the base of the thumb when the area was struck
or compressed, but he did not have all of the signs and
symptoms of carpal tunnel syndrome. Because of his
history, the wound was explored. The median nerve was
found to be intact, but there was a fragment of glass
embedded within the epineurium. The fragment was well
walled-off, and one small fascicle of the nerve to the
thumb was partially divided with a neuroma in continuity,
which explained his symptoms. This could have been
avoided if thorough debridement and enlargement of the
wound had been done before closure during the initial
treatment.
tar
In industry, many materials such as grease, paint and
pressur e and transmi tted under pressur e
products are put under
When a patient arrives with a small
through guns and sprays.
of material
puncture wound and has a history of the injection
s an emerge ncy situatio n. There
under pressure, this become
surface althoug h it does not give any
may be material under the
evidenc e of swelling or enlarge ment. If
immediate symptoms or
to elapse, the wound will become
several hours are allowed
reaction to the
tender and cellulitis may appear as tissue
ted. As tension develop s in the
substance is being manifes
to necrosis. If
wound, further tissue disruption occurs, leading
may be irreparable
the wound is opened at this late date, there
more problems than
destruction evident. Grease and oils cause
for vehicles can also cause a
latex paint; undercoating materials
to be relieved of the
destructive process. The wound has
be cleansed of all of the
tension, and the tissues have to
under the best of circum-
irritating injected material. Even
lost, but this can be kept toa
stances, at times portions will be
and debridement as an
minimum with proper decompression
emergency procedure.
88 J. A. ARMINIO

a Z.

HIiGAGe Caulking compound was injected into the thenar eminence of the
hand.

FIG. 7. Immediate decompression and debridement was carried out while

preserving the neurovascular structures.
PENETRATING WOUNDS 89

al

g thumb.
FIG. 8. The final result is a functionin
90 J. A. ARMINIO

Case 5. A worker presented with a puncture wound to

the thenar eminence of the hand (Fig. 6). Caulking
compound under pressure from a caulking gun had been
injected into this area. Immediate decompression and
debridement were carried out, while preserving the neuro-
vascular structures (Fig. 7). These procedures were success-
ful and the final result was a functioning thumb (Fig. 8).

Gun Shot Wounds

Gun shot wounds in civilian life are usually at close range or
from low-velocity missiles. Often they are shotgun injuries with
wide destruction. The shot, the wad and particles of clothing
can be deeply embedded in the wound. Again, thorough
debridement must be carried out. A .22-caliber rifle with a
low-velocity missile acts differently than the high-velocity
missile used in military action. Delayed closure is indicated for
high-velocity missiles and, because of the large area of skin loss
at the site of exit, pedicle flaps may have to be used for
coverage of the defect. The initial procedure of wound care is
careful excision of the devitalized structures and delayed
primary or early secondary closure.

Self-Evaluation Quiz

1. Only a minor knowledge of the anatomy of the hand is

necessary for the treatment of penetrating wounds of the
hand.
a) True
b) False
2. The appearance of a wound when presented can be taken at
face value for what it appears to be, and the examiner can
treat the wound as is.
a) True
b) False
3. The initial examiner should always examine the wound and
the part carefully, as well as document and record the
findings for subsequent review.
a) True
b) False
PENETRATING WOUNDS 91

4, Debridement should be adequate and carried out well, but

some questionably viable tissue can be allowed to remain in
the wound at the time of the initial debridement.
a) True
b) False
Some types of foreign material can be left in the wound
without causing impairment of function.
a) True
b) False
Salvage of parts should always be kept in mind, and these
of
parts can be disposed of when there is no further need
them in the reconstruction.
a) True
b) False
wound
Following an injury, if the history dictates, the
carried out meticu -
should be reexplored; this should be
recurr ence of symp-
lously to determine the cause of the
toms.
a) True
b) False
are more
The organisms and flora in the mouth of an animal
virulent than those in a human mouth .
a) True
b) False
d satisfactorily
A pressure-gun injection injury can be treate
will occur before the
by waiting and watching to see what
wound is drained.
a) True
b) False
only minimal injury to a part
10. Low-velocity missiles cause
that is struck.
a) True
b) False

Answers on page 527.

 — . te ia

n i " B hed 2 7.
eel) hee |

rea
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~ singling
CASO RN mI Te Aw ri,4 bom elon eee
 Management of Flaps in Hand
Surgery
Ivens C. LeFlore, M.D.

Objectives

The purpose of this presentation is to discuss the

management of flaps in hand surgery, including the
indications, surgical techniques and complications.

e flaps for
Most acute injuries of the hand do not requir
r, when indica ted, a knowle dge of the
wound closure. Howeve
its manag ement is essenti al for achieving
appropriate flap and
mainta ining maxim um functi on.
wound healing and
ut exposing
When an injury involves only skin loss witho
or a full-thickness
deep structures, a split-thickness skin graft
does expose blood
skin graft can be applied. When the injury
coverage with a flap,
vessels, nerves, periosteum or tendons,
subcutaneous tissue, is
which includes epidermis, dermis and
ures to heal and
necessary to allow the underlying struct
will not suffice since its
maintain normal function. A skin graft
blood supply from the
survival depends on obtaining a
underlying bed.
graft, careful attention
Prior to the use of any flap or skin
e and removal of all foreign
to debridement of all nonviable tissu
adequate hemostasis are
materials, copious irrigation and
necessary.
eon should choose the
When selecting a flap, the hand surg
the desired end result with
simplest flap that will accomplish
idity.
the least amount of patient morb
Flaps in hand surg ery can be divided into local flaps and

Washington,
te Practice in Hand Surgery,
Ivens C. LeFlore, M.D., Priva
D.C.

93
94 I. C. LEFLORE

skin and subcutaneous tissue in one stage. Distant flaps require

a minimum of two operations and coverage of the donor site
with a split-thickness skin graft.
The best example of a local flap is the finger tip amputation
when maintenance of length of the phalanx is important. Two
basic types of flaps are used: the Kutler or double lateral
advancement flap (Fig. 1) and the Kleinert ““V” to “Y” volar
advancement flap (Fig. 2).
The advantages of the first two are that they can be
performed under local anesthesia in most cases, are single-stage
procedures, do not require immobilization of the extremity, do
not create a donor defect and usually maintain sensation. Care
must be taken in designing these flaps so that the length is
sufficient to cover the amputated defect.
The examples of distant flaps are the thenar or hypothenar
flap (Fig. 3), the cross-finger flap (Fig. 4), the cross-arm flap
(Fig. 5A), the abdominal flap and the chest flap (Fig. 5B).

FIG. 1. Kutler or double lateral advancement flaps.

MANAGEMENT OF FLAPS 95

We
advancement flap.
FIG. 2. Kleinert volar ‘“‘V’’ to “Y”’
96 I. C. LEFLORE

FIG. 3. Hypothenar flap.

MANAGEMENT OF FLAPS 97

FIG. 4. Cross-finger flap.

98 I. C. LEFLORE

(B)

(A)

FIG. 5. (A) Cross-arm flap. (B) Abdominal flap.

These flaps usually require general anesthesia or axillary

block. Following the initial surgery, careful postoperative care
of the wound, flap and donor site is essential. Care in
positioning to prevent angulation or tension on the flap during
the healing phase ensures adequate blood supply and early
revascularization from the surrounding tissues. Of equal impor-
tance is to extend the skin graft of the donor site to cover all
raw or exposed surfaces of the flap to decrease the possibility of
infection. The donor-site dressing should be changed every two
to three days to prevent infection and maceration of the skin
graft. When these postoperative steps are followed, the flap can
be divided and inset in 10 to 14 days. Some surgeons prefer to
MANAGEMENT OF FLAPS 99

divide the flaps at ten days and delay final suturing for 48
hours.
The success of these flaps is dependent upon designing the
flap(s) so that the width and length are sufficient to cover the
defect without undue tension; careful handling of the flaps with
skin hooks and not forceps; undermining of the subcutaneous
tissues after incising the skin, only to the extent necessary for
adequate mobilization but without injury to the neurovascular
supply. The flaps are carefully sutured with 5.0 or 6.0 nylon.
Xeroform is used to cover the wound and a fine-mesh gauze
added for protection. A drain is not necessary.
A disadvantage of the distant flap is a sometimes painful
donor site, especially when using the thenar or hypothenar flap.
Distant flaps should not be used in patients over 50 years of
age, on stiff hands, infected hands or arthritic hands.
Today, since expertise has been gained with the use of the
operating microscope, the variety of flaps used in restoring
function to the injured hand has become almost unlimited. The
concept of axial or arterial vs. random flaps has been illumi-
nated. An axial flap is defined as a flap supplied by an artery
the
that maintains its name after passing through muscle, e.g.
in
transverse circumflex artery that supplies a well-defined flap
the groin. This flap can be elevated on its single arterial supply
then be
and two veins or venai comitantes. The vessels can
reanas-
transected, the free flap transferred and the vessels
recipient vessels in the open hand wound.
tomosed to similar
allows the
Unlike the distant flap, this microsurgical technique
tation of
surgery to be performed in a single stage. Reimplan
extremities is a form of free flap transfer.
given to
Whichever flap is selected, attention should be
stabilization,
proper positioning, lack of motion with good
donor site.
patient comfort and the resultant defect of the
debridement of
Optimal primary healing is accomplished by
by gentle handling of
all nonviable tissue in the injured hand,
ion to details of
tissues during surgery and by giving attent
wound care after surgery.

Acknowledgment
of Michael Parry, M.D.
Illustrations are provided courtesy
100 I. C. LEFLORE

Self-Evaluation Quiz

The cross-finger flap is an example of:

a) Free flap
b) Local flap
c) Donor defect
d) Distant flap
e) Proximal amputation
Early revascularization is best accomplished by all of the
following except:
a) Gentle tissue handling
b) Primary closure of the donor site
c) Use of skin hooks
d) Debridement of wounds
e) Positioning to prevent angulation
Distant flaps are more advantageous to cover finger tip
injuries.
a) True
b) False
An axial (arterial) flap is supplied by multiple perforating
capillaries.
a) True
b) False
Concerning local flaps, all of the following are correct
except:
a) Creates no donor defect
b) Requires general anesthesia
c) Does not require immobilization
d) Usually maintains adequate sensation
e) Are single-stage procedures

Answers on page 527.

Replantation and Revascularization
William B. Kleinman, M.D.

Objectives

To assess the goals of microvascular surgery.

To present considerations for and against replantation.
To review preliminary preparations for such procedures.
etl To discuss appropriate surgical techniques and post-
ae
operative management.
”

Microvascular surgery has, over the past 15 years, developed

into an important tool in the hand surgeon’s armamentarium.
s
The continuous rise in industrial and recreational accident
s ability to restore
places increasing demands on the surgeon’
n
hand function after complete amputation or devascularizatio
of vital parts of the upper limb.
ing
The fundamental goal of hand surgery using the operat
r techni ques remain s essenti ally
microscope and microvascula
inable by a
unchanged: restoration of limb function unatta
circula tion to and from a part after
prosthesis. Restoring only
ulariz ation can at times be an
amputation or severe devasc
e of postop erativ e compro mise to
injustice to the patient becaus
functio n. Each case should be evalua ted
the remainder of limb
; the indications
critically to weigh the benefits of microsurgery
to, surgery must be well-known to
for, and contraindications
the hand surgeon.
following digital
The reported success rates of 50% to 90%
tive. They represent
replantation, for example, can be decep
er final function nor
only viability of the replanted parts; neith
considered in statistical
the patient’s own satisfaction are
ntation surgery. Before
reports of survivability after repla

St. Vincent Hospital and Health Care

William B. Kleinman, M.D.,
Center, Indianapolis, Ind.

101
102 W. B. KLEINMAN

regarding a patient suitable for microvascular reconstruction,

four functional goals should be considered.
1. Can motion be restored in those joints included in the
amputated part?
2. Will the part be sensible and able to experience its
environment after replantation?
3. Will it be free of pain after a ‘“‘successful’’ replantation
or revascularization?
4. What will be the final cosmetic appearance of the limb?
Only after assessment of the prognosis for reaching these
functional goals should consideration be given to the final
appearance of the limb.

Indications for Replantation

Thumb
Because of its importance in prehension, and thus the entire
function of the human hand, replantation of the amputated
thumb is the foremost indication for microvascular surgery.
Only in the face of severe medical, psychiatric or age contraindi-
cations should replantation not be recommended in the patient
with a clean traumatic amputation through the thumb base.

Partial Hand
Prosthetic substitutions are usually poor in traumatic,
partial hand amputations. Efforts to restore the amputated part
should be made only if limb sensibility can be salvaged. As
noted, joint motion and tendon balance in the partial hand
amputation are a major concern in assessing reconstructive
microsurgical goals.

Multiple Digits
The most frequently seen indication for replantation at
centers equipped to treat hand trauma of this magnitude is the
multiple digital amputation. Because of the excessive amount of
surgery necessary to restore functional anatomy, patients in this
category should be immediately transported to hand centers
where a team of hand surgeons trained in microsurgical
techniques is available. A reconstructive effort in a four- or
five-finger amputation through the proximal phalanges may
REPLANTATION AND REVASCULARIZATION 103

take two or three teams of surgeons up to 20 hours before a

satisfactory result is achieved.

Any Part of a Child

Since the regenerative capacity of peripheral nerves is
decidedly better in children than in adults, and quality of the
intima and general elasticity of the vessels is excellent,
functional retum after replantation in children is usually
excellent. This includes single digital replantation other than the
thumb. In adults, because of frequent problems with stiffness,
cold intolerance, pain, economic loss and compromise to
uninjured parts, replantation of the single amputated digit
(other than the thumb) is contraindicated. In adults, ray
resection of border digits is recommended for early functional
return of the entire hand, and in nonborder amputations, ray
resection and transposition of the adjacent border ray centrally
is advised.

Whole Hand
As the level of amputation progresses from distal in the
digits to proximal in the forearm or arm, statistical survival of
the replanted part improves, specifically because of the increas-
ing size of the injured vessels; however, functional restoration
becomes increasingly more difficult as the level of primary
muscle
neurorrhaphy moves cephalad. In addition, the skeletal
mass, exquisitely sensitive to ischemia, increases in the proximal
palm and forearm, making the time between the traumatic
restora-
interruption of blood supply to the limb and surgical
secondary to ischemia is
tion of circulation critical. Myofibrosis
concern in ‘‘successfu l”’
the microvascular surgeon’s major
proximal forearm and arm replantations.

Levels of Amputation
injury to the
Daniel and Terzis have defined six zones of
progno sis for micro vascular
hand, each reflecting a different
of arteri es and veins distal
surgery. Because of fine arborization
nail, micro vascu lar anast omosi s is
to the germinal matrix of the
referr ed to as zone I. Betwe en
not recommended in this area, the
and the germin al matrix of
the distal interphalangeal joint in
may reach 0.5 to 1.0 mm
nail (zone II), digital arteries
104 W. B. KLEINMAN

diameter, and are suitable for anastomosis. The venous plexus,

however, is still too small to repair (except in the thumb) and
the 20% reported survival in zone II replantation efforts reflects
only those patients systemically anticoagulated after arterial
microvascular anastomosis alone. These patients have been
allowed to bleed freely into their dressings until spontaneous
venous recanalization can be achieved. The recognized risks and
potential complications in zone II weigh heavily against any
small functional improvements achieved by replantation in zone
II (except in the thumb, where dorsal veins are large enough to
repair).
Zone III includes the remainder of the fingers, distal to the
bifurcations of the common digital arteries, and is the most
common area for digital amputations treatable by microvascular
surgery. Zone IV is any part of the hand distal to the superficial
palmar arch, not including either the thumb or hypothenar/
thenar eminence.
In Zone V (distal wrist crease to superficial palmar arch)
and zone VI (any level proximal to the wrist) skeletal muscle
mass increases. The risks of poor functional return secondary to
ischemic fibrosis of devascularized muscle is more critical,
consequently, in amputations at these more proximal levels of
the limb.

Preparation of the Amputated Part

The prognosis for any replant effort begins at the scene of

the accident. Paramedical personnel are advised to cleanse the
part carefully, wrap it in sterile saline-soaked gauze, place it into
a plastic bag or container, and only then lay it on a bed of ice.
Extreme care is taken not to allow the tissue to be directly in
contact with the ice. In this manner, anaerobic catabolism is
minimized by a temperature of approximately 4 C; direct
contact, which would cause freezing and cellular crystallization,
is avoided.
We call the period between preparation of the amputated
part on a bed of ice and skeletal fixation of the part to the
patient’s stump by the microvascular team, the ‘‘cold-ischemia
time.” After skeletal fixation the part can no longer effectively
remain cool, anaerobic metabolism increases and irreversible
tissue devitalization begins. The interval between skeletal
REPLANTATION AND REVASCULARIZATION 105

fixation and restoration of oxygenated blood to the replanted

part is called the ‘‘warm-ischemia time.’ The urgency in
replantation surgery is to minimize the warm-ischemia time, and
thus the degree of anaerobic catabolism and compromise to
final function.

Preliminary Preparations

Once a careful history and physical examination of the

injured patient have ruled out contraindications to surgery
(Table 1), the surgeon is obligated to explain to the patient that
the operative procedure might be lengthy and difficult, that
there will be only a 50% to 75% chance of survival of the
replant, that the postoperative hospitalization will be at least 10
to 14 days (or as long asa month), and that one or two further
surgical procedures might be necessary to restore function to
the part, if it survives. The patient should also be told that he
will probably not be able to return to work for four to six
months.
Once the patient gives his ‘‘informed consent,” a CBC,
protime, activated partial thromboplastin time, and type and
crossmatch for 2 to 6 units of whole blood are sent to the
laboratory. Antibiotics are begun in the emergency room,
tetanus prophylaxis is administered and x-rays are obtained of
the chest, stump and amputated part.
During lengthy procedures under general anesthesia, a
renal
urinary catheter has proven quite useful in monitoring
output, especially when blood loss is massive. Under regional
is not
anesthesia with long-acting axillary block, catheterization

Table 1. Contraindications to Replantation

Medical Psychological
Anatomic
Generalized systemic trauma Stability
Zone I
Severe ASCVD Patient wishes
Zone II (except child,
Severe diabetes mellitus Vocational or
or adult thumb)
Severe anesthetic risk occupational
Single digit (except thumb)
Bleeding diathesis of PUD needs
Zone VI (if warm ischemia
greater than 6 hours)
Crushing injury
Avulsion
106 W. B. KLEINMAN

done, but urinary output is carefully monitored throughout the

case.
A pneumatic tourniquet is mandatory; in a patient systemic-
ally anticoagulated, blood loss can be extensive whenever the
tourniquet is released, and replacement must be carefully
monitored. Central venous pressure lines, although advised in
some reports, have not been necessary in our experience, even
in zone VI replantations. Tamai has clearly shown that the
tourniquet can be inflated and deflated multiple times on recent
anastomoses without compromise to the repair by sludging, so
long as the patient is systemically heparinized. We have had
similar experience with lengthy multiple digital anastomoses.

Surgical Technique

The same systemic approach should be used in each patient

suitable for microsurgical reconstruction. Skeletal fixation of
bone is performed first, with emphasis on shortening only to
debride necrotic edges and secure apposition of bone ends, not
to get the ends of vessels together for primary anastomosis.
Amputations which cross joints are treated by shortening and
primary arthrodesis in a position of function. After shortening,
if vessels cannot be brought together without tension for
primary anastomosis, vein grafts from the volar wrist are used.
The orientation of the intercalated graft must be reversed to
assure that venous valves will not obstruct the flow of arterial
blood.
Following internal fixation by either a single intramedullary
Kirschner wire or crossed K wires, the dorstal tendon mech-
anism (including lateral bands and central tendon) is repaired. If
crossed K wires are not used, rotation around a single
intramedullary pin can be controlled by the repaired dorsal
apparatus. Use of a single intramedullary wire is reeommended
to reduce the total warm-ischemia time.
‘All flexor tendon repairs and primary epineural nerve
repairs are done prior to microvascular anastomoses, which
constitute the majority of the warm-ischemia time. Arterial
microvascular anastomosis is then preformed to facilitate the
identification and repair of dorsal veins. These veins are
subsequently repaired in a ratio of at least 2:1, veins to arteries.
The cross-sectional area of venous drainage should be at least
REPLANTATION AND REVASCULARIZATION 107

twice that of arterial inflow, the basis for the 2:1 philosophy.
Usually, reestablishing inflow through a single artery is suf-
ficient; if flow is marginal, however, there should be no
hesitation to repair both digital arteries to ensure adequate
flow.

Postoperative Care

Immediately after surgery, patients are placed on a strict

protocol. Salicylates are given either PR or PO for a period of
three weeks. Intravenous low-molecular-weight dextran, begun
intraoperatively, continues for three to five days. Aspirin is felt
to be effective in inhibiting platelet aggregation at the site of
the anastomoses by reducing the adenosine diphosphate, sero-
tonin and epinephrine (so-called sticky substances) released at
the site of repair by the exposed thrombogenic surface of
underlying collagen. When the endothelial lining is interrupted,
this collagenous undersurface stimulates the conversion of
slippery, nonadherent spheroid platelets to a sticky mass. The
inherent electronegativity of the intimal lining of a blood vessel
has been shown to be somewhat stabilized by low-molecular-
weight dextran, keeping platelets (which are electronegative
in the
themselves) dispersed; it also acts by preventing sludging
microcirculation.
circula-
The vasoactive effects of nicotine on the peripheral
g is allowed in the patient ’s
tion are well known; no smokin
lizatio n. Arteria l spasm second-
room during the entire hospita
ted with
ary to increased circulating catecholamines associa
by not changin g the patient’s
stress, pain or anxiety is avoided
dressing during the first ten days.
is monitored
The status of the replant or revascularized part
nt clinica l observ ation of nailbed
quite closely, with freque
ature probes
color, capillary refill and bleeding. Surface temper
Univer sity can be of some assistance in
as described at Duke
flow to the part.
alerting the surgeon to early changes in blood
in the early posto perat ive period will
Vascular compromise
on must decide on the
be either arterial or venous, and the surge
er the position of the
basis of his clinical observations wheth
more dependent. Stellate
limb should be more elevated, or
adjuncts in difficult
ganglion blocks have proved to be useful
cases refractory to other measures.
108 W. B. KLEINMAN

Our indications for heparin systemic anticoagulation are in

those cases where the tourniquet is inflated and deflated
multiple times in the face of recent anastomoses, or in
situations where despite excellent repairs, persistent spasm
proximally makes flow sluggish into the replanted part. If we
feel there may have been some unusual technical difficulty
which predisposed to postoperative thrombosis and circulatory
failure, the patient will be taken back to the operating room for
attempted revision. But the best surgical effort is made at the
time of primary anastomosis, and only in extenuating circum-
stances will a revision be performed.

Summary

The replantation team must be practiced, accessible around

the clock, available in enough numbers to avoid fatigue, and
ready to persevere in the face of what sometimes appears to be
an impossible situation. Facility and expertise with the operat-
ing microscope are mandatory, and availability of the best
equipment is essential. With these and a patient free of
contraindications, restoration of function by replantation of
tissue with the aid of microvascular techniques can become an
important and useful asset to the hand surgeon.

Bibliography
Bunche, H.J.: Digital transplantation. In Littler, J.W., Cramer, L.M. and
Smith, J.W. (eds.): Symposium on Reconstructive Hand Surgery. St.
Louis:C. V. Mosby Co., 1974.
Daniel, R.K. and Terzis, J.K.: Reconstructive Microsurgery, ed. 1.
Boston: Little, Brown & Co., 1977.
Gelberman, R.H., Urbaniak, J.R., Bright, D.S. and Levin, L.S.: Digital
sensibility following replantation. J. Hand Surg. 3 (4):313, 1978.
Harashina, T. and Bunche, H.J.: Study of washout solutions for
microvascular replantation and transplantation. Plast. Reconstr. Surg.
DOso42 Oar
Kleinert, H.E., Kasdan, M.L. and Rowers, J.L.: Small blood-vessel
anastomsosis for salvage of severely injured upper extremity. J. Bone
Joint Surg. 45:788, 1963.
Kleinert, H.E., Kutz, J.E., Atasoy, E. et al: Replantation of non-viable
digits — Ten years’ experience. J. Bone Joint Surg. 56:1092, 1974.
O’Brien, B.M.: Replantation surgery. Clin. Plast. Surg. 1:405, 1974.
O’Brien, B.M.: Digital reattachment and revascularization. J. Bone Joint
SULg oo al AaaO73.
REPLANTATION AND REVASCULARIZATION 109

Sarin, C.L., Austin, J.C. and Nickel, W.O.: Effect of smoking on digital
blood-flow velocity. JAMA 229:1329, 1974.
Stirratt, C.R., Seaber, A.V., Urbaniak, J.R. and Bright, D.S.: Temperature
monitoring in digital replantation. J. Hand Surg. 3 (4):332, 1978.
Tamai, S.: Multiple digit replantation. Jn Daniel, R.K. and Terzis, J.K.
(eds.): Reconstructive Microsurgery. Boston:Little, Brown & Co.,
STs Sayer, PPS Tiley
Winfrey, E.W. and Foster, J.H.: Low molecular weight dextran in small
artery surgery. Arch. Surg. 88:78, 1964.

Self-Evaluation Quiz

1. In partial hand amputations, joint motion and tendon

balance are the major concerns.
a) True
b) False
2. Funetional return after replantation of any hand part is
usually excellent in children.
a) True
b) False
3. The major concern in proximal forearm and arm replanta-
tion is:
a) Pain
b) Stiffness
c) Survival of the part
d) Myofibrosis
4. Use of which of the following is mandatory?
a) Central venous pressure lines
b) Urinary catheter
c) Pneumatic tourniquet
d) All of the above
e) None of the above
should be done to
5. In skeletal fixation, bone shortening
permit primary anastomosis of vessel ends.
ae rue
b) False
6. The proper sequence of repair is:
a) Dorsal tendon mechanism repair
b) Primary artery /vein anastomosis
c) Flexor tendon repair
d) Venous microvascular anstomosis
e) Skeletal fixation
110 W. B. KLEINMAN

f) Arterial microvascular anastomosis

g) Primary epineural nerve repair
7. Low-molecular-weight dextran reduces “‘sticky substances”’
at the site of repair.
a) True
b) False
8. The status of the replant is monitored by frequent
observation of:
a) Nailbed color
b) Capillary refill
c) Bleeding
d) Surface temperature
e) Pain

Answers on page 527.

 Sensibility Evaluation
Evelyn J. Mackin, L.P.T.

Objectives

Many tests have been developed to evaluate sensory

function, including two-point discrimination, the ninhydrin
sweat test, Moberg pick-up test, and the Semmes-Weinstein
monofilaments. Administration of these tests is described.

Testing the hand to determine sensibility is of primary

with
importance to the surgeon and therapist treating patients
ng
sustained peripheral nerve injuries. As a patient is recoveri
he can
from an injury, it becomes necessary to know what tasks
and to
perform with the sensibility remaining in his hand
determine whether the lost sensibility is returning.
lity is
A systematic method of testing and recording sensibi
standa rdized and
essential. Yet, in an age that demands a
ns vary. Many
reliable test, testing techniques and opinio
-wool (touch),
procedures are now used: pinprick (pain), cotton
Tinel sign [4],
Weber two-point [1, 2], Moberg pick-up [3],
iomete r [1, 6],
vibration [5], Semmes-Weinstein pressure esthes
rin sweat [3, TA,
moving touch vs. constant touch [5], ninhyd
[9, 10].
Seddon coin [8] and sensory nerve conduction
divided into four
The tests used to study sensibility may be
(1) the four primary
groups, based on the examination of
es-We inste in mono-
modalities — cold, warmth, touch (Semm
[11, 12] (two-point
filaments) and pain; (2) tactile gnosis
(3) sweat secretion;
discrimination and Moberg pick-up test);
condu ction ).
and (4) electromyography (sensory nerve
the finger pulps that
Tactile gnosis is the fine sensibility of
touc hed without the aid of
permits recognition ot what is being

Hand Therapy, Hand Rehabilita-

Evelyn J. Mackin, L.P.T., Director,
tion Center, Ltd., Philadelphia, Pa.

ie bal
112 E. J. MACKIN

sight. Moberg [13] has stated that a hand without tactile gnosis
is “blind”? and is useless without the aid of vision. For this
reason every examination of sensibility in the hand must
include a test of tactile gnosis.

Initial Examination

The initial examination indicates the extent of testing

necessary and should include the following data:
al: History. Record of date of injury, location of injury,
diagnosis, surgery and pertinent information.
2. Subjective description by patient. Include the patient’s
description of his hand (numbness, pins and needles,
pain, burning, ability to use it in daily activities. Include
those activities that make his symptoms worse. Not all
patients are good historians: what is numbness to one
patient may seem normal to another. Reevaluation of a
patient who states that his hand feels fine may show a
measurable sensory loss.
Objective assessment by examiner. Include observation
of trophic changes, joint contractures, skin condition
(dry or moist) or presence of edema. Note burns,
blisters, cuts or bruises on the fingers that are indicative
of the insensitive hand. Also include the mood and
cooperativeness of the patient, his ability to follow
instructions, and problems with communication (vision,
hearing, speech).
Joint range-of-motion evaluation. Record range-of-
motion measurements (active and passive) for the joints
of the fingers, hand and wrist.
Muscle evaluation. Record weakness in muscles of the
hand. Identify normal muscles. Measure muscle bulk in
the forearm and compare with that of the uninvolved
extremity. Describe coordination and record the pres-
ence of pain as related to muscle function. Check
prehension and grasp measurements as compared to
those of the uninvolved extremity. Grip strength is
measured on the adjustable Jamar dynamometer (Fig.
1). The combined efforts of the intrinsic and extrinsic
muscles are evaluated on levels 2 and 3, whereas isolated
FIG. 1. Jamar dynamometer.
114 E. J. MACKIN

intrinsic muscle function is evaluated on level 1 and

isolated extrinsic muscle function is evaluated on levels
4 and 5.
6. Proprioception. For this test the patient is blindfolded.
The examiner supports the patient’s finger laterally and
moves it 0.5 to 1.0 cm in any direction. The patient
must identify the angle through which the joint is
moved.

Two-Point Discrimination

Light-touch two-point discrimination establishes the pres-

ence of epicritic sensibility, or the fine sensibility required to
manipulate small objects. Moberg [3] feels that the two-point
discrimination test provides the most useful information about
the functional status of the hand; however, he concedes that the
test is not ideal since it requires the patient’s cooperation. He
prefers to use an ordinary paper clip with a wire diameter of
about 0.9 mm as the testing instrument.
Many examiners prefer to use a Boley gauge for testing
because the exact distance in millimeters is measured (Fig. 2).

FIG. 2. Boley gauge.

SENSIBILITY EVALUATION MALS

The gauge is set at 6 mm (standardized by the American Society

for Surgery of the Hand as normal). The patient’s hand must be
stabilized against a table by the examiner’s hand. The patient is
asked to discriminate between being touched with one or two
points. If testing at 6 mm is incorrect, the distance between the
two points on the gauge is increased until the patient can
identify seven out of ten responses, or is determined untestable
when the gauge is set at 20 mm. Both prongs of the Boley gauge
must touch the skin at the same instant and the skin should not
blanch. The Society recommends that the prongs be applied in a
longitudinal direction.

Moberg Pick-up

The patient, with his eyes open, is asked to pick up small

objects one at a time from a table and place them quickly ina
box (Fig. 3), first using the uninvolved hand and then the
injured hand. He is then blindfolded and asked to repeat the
exercise. Timing and the manner in which the patient handles
the objects are recorded, and a comparison is made between the
injured and the uninvolved hand. If sensibility in the median

FIG. 3. Moberg pick-up test.

116 E. J. MACKIN

nerve is impaired, the patient will pick up the objects with the
thumb plus the ring and little fingers, instead of the normally
used thumb and index. The test can be made more difficult by
asking the patient to name or describe the objects as he picks
them up [3].

Semmes-Weinstein Monofilaments

Von Frey [14] first described the use of pressure-sensitive

monofilaments to evaluate cutaneous sensibility in the late
1800s. He found that horsehairs of varying thicknesses would
bend at specific milligrams of axial loading pressure. By pressing
on the skin with a thorn glued to the end of a hair until the hair
started to bow out, von Frey obtained a measure of the pressure
sensibility of nerve fibers in the skin. He calibrated the hairs on
a balance, varying the stiffness by changing length or by using
hairs of different density. He recorded the pressure sensibility
by noting whether a given hair touched to the skin produced
any sensation [15].
Semmes and Weinstein [6] made the testing procedure
more exact when they introduced nylon filaments (Fig. 4) set in

FIG. 4. Semmes-Weinstein monofilament.

SENSIBILITY EVALUATION ay

individual lucite rods. These filaments are calibrated to exert

specific stress. Twenty graduated filaments, varying in pressure,
are included in the testing kit. The filaments, except for the
very largest, buckle as the examiner presses them against the
skin. The stress exerted on the skin is due to the length and
diameter of the calibrated filament, not the stress exerted by
the examiner, as long as first-order buckling is maintained.
First-order buckling is that which a carefully applied Semmes-
Weinstein filament undergoes. The upper end of the filament is
built into the handle and the lower end is “‘pinned.”’ The pinned
condition is achieved in contact with the skin when the
examiner applies the lateral forces necessary to keep the top
end directly above the lower end.
Von Prince and Butler [16] correlated two-point discrimi-
nation and perception of light touch as measured by the
monofilaments to develop a scale of interpretation which
divides the patient’s performance into graduated levels of
sensibility: normal, diminished light touch, diminished pro-
tective sensation and loss of protective sensation. Werner and
Omer [1] further modified this scale by classifying the patient’s
response according to area localization as compared with point
localization:
1. Area localization. The therapist has a work sheet on
which a hand has been divided into grid-like zones.
While these zones do not correspond to the classic
innervation patterns of the hand, they do facilitate
systematic testing and recording of results. The exam-
iner visualizes the grid-like zones on the patient’s hand
the
and applies a filament to the center of a zone while
soon as the patient
patient’s eyes are closed. As
word
perceives the stimulus, he responds by saying the
and touches the spot
“touch.”? He then opens his eyes
A correct respons e
he believes to have been stimulated.
dowel end touches inside
is one in which the 3/8-inch
have to touch
the zone stimulated. The patient does not
to recogni ze stimulation
the exact spot. This ability
within a particular zone is area localiza tion.
applies a filament to
2. Point localization. The examiner
the center of a zone while the patie nt’s eyes are closed.
perce ives the stimulus, he
As soon as the patient
118 E. J. MACKIN

responds with “‘touch.”? He then opens his eyes and

touches the spot he believes to have been stimulated. A
correct response is one in which the dowel is in contact
with the skin point stimulated. Point localization, as
compared to area localization, is considered a finer level
of appreciation of light-touch stimulation.
According to a study conducted by Levin et al [15] at the
Duke University Medical Center, the Semmes-Weinstein fila-
ments are simple to use; however, correctly interpreting the
results requires an understanding of the factors which can
influence those results. According to their engineering analysis,
the principal factors that can lead to variations in the stress
required to buckle a filament are (1) the method of application
by the examiner, (2) variations in the elastic modulus due to
elevated temperatures or high humidity, (3) differences in the
surfaces on the ends of the filaments, and (4) variations in the
attachment of the filaments to the handles.
Over 300 patients have been tested at the Philadelphia Hand
Rehabilitation Center, using Semmes-Weinstein monofilaments.
In spite of the variables discussed above, these filaments are
useful in establishing levels of sensibility. When the same
examiner carefully performs the test, and the method of
interpretation is clearly understood by the surgeon and ther-
apist, testing with the Semmes-Weinstein monofilaments can be
a valuable adjunct to other tests given.

Ninhydrin Sweat Test

The secretion of sweat is regulated by the sympathetic

nervous system. The fibers of the sympathetic nervous system
enter the brachial plexus in the far-proximal cervical region, in
the form of postganglionic fibers, and then follow the sensory
pathways out to the periphery. When there is a peripheral nerve
laceration the region of the skin innervated by it stops sweating.
Sweat contains amino acids and lower peptides. Ninhydrin
stains amino acids and lower peptides with great sensitivity. To
perform this test, the patient presses a moist finger (dry hands
thoroughly after washing) steadily against a piece of paper,
rolling the finger from side to side to obtain contact with the
lateral surfaces. The outline of the finger is traced with a pencil
SENSIBILITY EVALUATION 119

containing no dye. The paper is sprayed with ninhydrin and the

orifices of the functioning sweat glands are shown in the print.
The region with intact sensory function sweats normally and
gives normal prints, but the denervated regions leave no print at
all [3].
It is important to standardize ambient conditions, such as
temperature and humidity, and note the patient’s anxiety level
to obtain repeatable results. The greatest advantages of the
ninhydrin printing method are that it is completely objective
and the original test can be kept.

Sensory Nerve Conduction

Nerve conduction-velocity testing measures the speed at

which impulses travel over the course of a peripheral nerve. It is
an important tool for evaluating the functional status of this
nerve. At the Hand Rehabilitation Center, where patients are
tested for both sensibility and nerve conduction, it has been
found that when a loss of sensibility is measured by the
monofilaments, there is also a delayed or untestable nerve
conduction.

Conclusion

The development of microsurgical techniques requires reli-

able methods of testing sensibility. It is hoped that research
being carried on by the hand team — the surgeon, the
bioengineer and the hand therapist — at various hand centers
will lead to a standardized testing procedure.

References
cutaneous pressure sensitiv-
1. Werner, J.L. and Omer, G.E.: Evaluating
ity of the hand. Am. J. Occup. Miners Asolo Or
Data cited by Sherri ngton, C.S. in Shafer’s Textbook of
2. Weber, E.H.:
Physiology. Edinburgh, 1900.
determining the functional value
3. Moberg, E.: Objective methods for
of sensibility of the hand. J. Bone Joint Surg. 40B:454-476, 1958.
The “tingl ing” sign in periph eral nerve lesions, Kaplan, B.
A. Tinel, J.:
(trans.).Press Med. 47:388-389, 1915.
on, M.L.: Evaluating recovery of
5. Dellon, A.L., Curtis, R.M. and Edgert
nerve injury. Johns Hopkins Med. J.
sensation in the hand following
130:2 35-24 3, 1972.
120 E. J. MACKIN

6. Semmes, J., Weinstein, S., Ghent, L. and Teaber, H.L.: Somatosensory

Changes After Penetrating Brain Wounds in Man. Cambridge:Harvard
University Press, 1960.
. Aschan, W. and Moberg, E.: The ninhydrin finger printing test used to
map out partial lesions to hand nerves. Acta Chir. Scand.
1232365-31707 1962:
. Seddon, H.J.: Surgical Disorders of the Peripheral Nerves. Baltimore:
Williams & Wilkins Co., 1972.
. Staas, W.E.: Errors in interpretation of nerve conduction velocity. In
Hunter, Schneider, Mackin and Bell (eds.): Rehabilitation of the
Hand. St. Louis:C. V. Mosby Company, 1978, pp. 331-337.
10. Almquist, E. and Eeg-Olofsson, O.: Sensory nerve conduction velocity
and two-point discrimination in sutured nerves. J. Bone Joint Surg.
BNE alee), USO)
iil. Broman, T.: Om tekniken vid den _ kliniska sensibilitetsunder-
sokningen. Sven. Lakartidn. 42:2205, 1945. (Swedish. )
WA, Broman, T.: Can a refined method be of importance in clinical
investigations of sensibility? Nord. Med. 27:1801, 1945. (Swedish. )
13. Moberg, E.: Sensibility in reconstructive limb surgery. In Symposium
on the Neurologic Aspects of Plastic Surgery. St. Louis:C. V. Mosby
Company, 1978, pp. 30-35.
14. Von Frey, M. and Kiesow, F.: Uber die Function der Tastkorperchen
Yeit. Psychol. Physiol. Sinnes. 20:126, 1899.
15. Levin, S., Pearsall, G. and Ruderman, R.: Von Frey’s method of
measuring pressure sensibility in the hand: An engineering analysis of
the Weinstein-Semmes pressure aesthesiometer.
LG. Von Prince, K. and Butler, B.: Measuring sensory function of the hand
in peripheral nerve injuries. Am. J. Occup. Ther. 21:385-396, 1967.

Self-Evaluation Quiz

Sensibility evaluation assesses the sensory function a

peripheral nerves following injury and repair.
a) True
b) False
The sensory ability that permits us to recognize that we are
touching without the aid of sight has been called tactile
gnosis.
a) True
b) False
Burns, blisters, cuts or bruises on a patient’s hand are
merely an indication that the patient is clumsy.
a) True
b) False
Light two-point discrimination establishes the presence of
the fine sensibility required to manipulate small objects.
SENSIBILITY EVALUATION IPL

a) True
b) False
When testing two-point discrimination, the gauge is set at 10
mm, the setting standardized by the American Society for
Surgery of the Hand.
a) True
b) False
When vision is occluded, the patient with impaired median
nerve sensibility will pick up objects with the thumb and
index finger.
a) True
b) False
The Semmes-Weinstein pressure-sensitive monofilaments
evaluate cutaneous sensibility.
a) True
b) False
Area localization is the same as point localization.
a) True
b) False
An important advantage of the ninhydrin sweat test is that
it is completely objective.
cUY Abate
b) False
10. Nerve conduction velocity measures the speed at which
impulses travel over the course of a peripheral nerve.
a) True
b) False

Answers on page 527.

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 Sensibility Reeducation
Evelyn J. Mackin, L.P.T.

Objectives

The described methods of sensibility reeducation of the

hand are based on a study undertaken by Dellon et al [1,
2] to determine whether, following nerve injury, a patient
could improve to recover functional sensation. They pre-
sented evidence to support their theory that a patient can
improve his functional sensation through reeducation.

Sensibility return may depend in some part on how much

sensibility the patient needs in his activities of daily living. Ifa
fifth finger is involved and the patient does not need it very
much in his work, he may not get gcod sensibility return in the
finger. A patient who is a pianist, by using the finger during
hours of practice, may retrain himself, thus improving acuity of
be the
the sensibility of the finger — but this may not always
case.
did a
Dellon et al [1, 2], at the Johns Hopkins Hospital,
field
study based on the theory that the peripheral receptive
a sensory
changes after a nerve laceration, and developed
program in which patients are assigned specific
reeducation
their recovery
sensory exercises at the appropriate time in
process.
failure to
A sensory reeducation program assumes that the
ion in the adult
achieve recovery of normal functional sensat
patien t to achiev e
hand following nerve injury is a failure of the
ore, the progra m
his full postoperative sensory potential. Theref
tly in his central
reeducates the patient to interpret correc
profile of afferent
nervous system the postinjury, altered
periph eral stimuli.
impulses that occur from previously known
Hand Therapy, Hand Rehabilita-
Evelyn J. Mackin, L.P.T., Director,
tion Center, Ltd., Philadelphia, Pa.

123
124 E. J. MACKIN

Mountcastle and his co-workers [3] subdivided A-beta nerve

fibers, the thick myelinated fibers responsible for the percep-
tion of touch, into two separate groups on the basis of the
response to stimulation of their cutaneous receptors. The slowly
adapting fibers (10% of the fibers) respond to the stimulus and
then fire continuously until the stimulus stops. The quickly
adapting fibers (90% of the fibers) respond to the stimulus with
a short burst of firing and then stop firing even if the stimulus
continues. The tests are specifically designed to evaluate the
quickly and slowly adapting capacities of these fibers.
Dellon et al found that sensory recovery occurred in the
following sequence: pain, vibration of 30 cps (hertz), moving
touch, constant touch and vibration of 256 cps (hertz).

Testing Technique

A quiet testing area is necessary. Any sound may be

distracting to the patient. A demonstration of the testing
procedure should be done on the uninvolved hand first so that
the patient is familiar with the stimulus. Each stimulus is
applied to a proximal area first, with further testing distally
until the stimulus is no longer felt. The tuning fork (Fig. 1) is

FIG. 1. Tuning fork, placed in the direction of its vibration, touches the
test area.
SENSIBILITY REEDUCATION 125

struck upon the table and held so that its tip, placed in the
direction of its vibrating, touches the test area. The line
indicating where a moving-touch stimulus is perceived is
determined by the examiner’s fingertip stroking the test area. In
a similar manner, the constant-touch line is determined by the
examiner’s fingertip being pressed and held motionless upon the
test area (Fig. 2).
The patient’s peripheral sensation is evaluated and recorded
on a chart. He is tested at regular intervals and his pattern of
sensory recovery recorded.

Early-Phase Reeducation

Early-phase reeducation may be started two months after

nerve repair. The patient will feel the vibration of the 30-cps
tuning fork at about the same time he feels moving touch. This
provides a guide to the patient’s progress. The therapist maps
out how far distally the patient feels the tuning fork, and then
the area where he feels moving touch. The patient should be
able to perceive moving touch to the same distal point. If he
does not, then he is a candidate for sensory reeducation in

by the examiner’s fingertip being

FIG. 2. Constant touch is determined
the test area.
pressed and held motionless upon
126 E. J. MACKIN

moving touch. The therapist notes the area on the chart where
the patient does not feel moving touch and has him stroke on
this area with heavy moving touch at first, then later with light
moving touch. The fingertip may be used in training.
A similar procedure is followed for constant touch. Since
the slowly adapting fibers that mediate constant touch regen-
erate ahead of the fast fibers that mediate vibration of the
256-cps tuning fork, the patient should be able to perceive a
constant-touch stimulus as far distally as he is able to perceive
this tuning fork. If not; i.e., if he can perceive the tuning fork
but not a constant touch stimulus, he is ready for sensory
reeducation in constant touch. A pencil eraser is used for this
training.
If the patient experiences any burning or paresthesia, the
treatment should be temporarily discontinued. A pain-free hand
is essential. Painful hands are not conducive to the perception
of reeducation exercises.

Late-Phase Reeducation

Late-phase reeducation is designed to recover better func-

tional sensation in the hand and may be begun whenever the
perception of constant touch has returned at the distal
fingertip. This phase deals with a mature nerve. Late-phase
reeducation should not be initiated until there has been no
change in the patient’s two-point discrimination on weekly
testing and this plateau has been maintained for three successive
weeks. Seven correct responses out of ten trials of being
touched with both points simultaneously are taken as a positive
response.
Late-phase exercises are simple, repetitive and may be done
at home by the patient and in a private and quiet room. There
are two basic exercises.
1. Numbers. The therapist writes a number on the patient’s
fingertip with a cuticle stick, starting with numbers 1, 3, 6, 9.
The patient begins the training with his eyes open as the
therapist writes the number on the entire distal interphalangeal
area. For reinforcement, the patient should say out loud the
number being written. The patient then closes his eyes (or looks
away) and the therapist writes the same number on the same
fingertip. The patient may feel the number being written;
SENSIBILITY REEDUCATION 127

however, there may be no cognizance of the number or

direction of movement. Repeat the procedure.
It is important to write the numbers in the style the patient
would write them (Fig. 3). People write differently, and when
his eyes are closed the patient will visualize the numbers as he
would normally write them. The therapist also must write the
number on the fingertip so that it is facing the patient. Begin
with the entire distal interphalangeal area and when the patient
can correctly identify the numbers 1, 3, 6 and 9, write the same
numbers on half the distal interphalangeal area. When the
patient can correctly distinguish the numbers on half the distal
interphalangeal area, use different numbers: 2 and 5.
2. Hexagonal Nuts, Washers and Coins:
Hexagonal nuts. The patient attempts to discriminate
differences in diameter between metallic hexagonal nuts of
various sizes. The hexagonal nut is pressed by the uninjured
hand or another person onto the test area, the fingertip of the
injured hand. The patient presses twice on his fingertip, first
with his eyes open and observing the stimulus, and then
repeating the stimulus with his eyes shut, concentrating on the
sensation evoked by the stimulus. The patient observes the

tip.
FIG. 3. Number written on the finger
128 E. J. MACKIN

stimulus, thinks about it and how it feels as he watches it. Then

he repeats the stimulus with his eyes closed and forces his
attention on how it feels. He must concentrate on associating
whatever altered profile of impulses he is receiving centrally
with what he “knows” is happening at his fingertip. Repeat
with a small hexagonal nut, the stated goal being for the patient
to distinguish, when tested the following week by the examiner,
the large from the small hexagonal nut. The actual goal, of
course, is to increase the patient’s ability to interpret subtle
differences in constant-touch stimuli. The improvement will be
directly measurable by the two-point discrimination test, which
will be repeated weekly.
Washers and coins. Using a washer with a round edge, and a
coin with a knurled edge, the patient attempts to distinguish the
round edge from the knurled edge.
The hexagonal nut type of exercise (Fig. 4) is effective in
median nerve injuries. The nut may be rolled and pressed
between the thumb and the index finger, yielding improvement
in two-point discrimination in both fingers and simultaneously
aiding motor rehabilitation. The exercises should be done 10 to
15 minutes per time and repeated three to four times a day.
Improvements in two-point discrimination should be noticed
within three to eight weeks on exercise.

FIG. 4. Hexagonal nut rolled between the thumb and index finger is an
effective exercise in median nerve injuries.
SENSIBILITY REEDUCATION 129

References

1. Dellon, A.L., Curtis, R.M. and Edgerton, M.T.: Evaluating recovery of

sensation in the hand following nerve injury. Johns Hopkins Med. J.
130:235-243, 1972.
2. Maynard, C.J.: Sensory re-education following peripheral nerve injury.
In Hunter, Schneider, Mackin and Bell (eds.): Rehabilitation of the
Hand. St. Louis:C. V. Mosby Co., 1978, pp. 318-323.
3. Mountcastle, V.B.: Medical Physiology, ed. 12. St. Louis:C. V. Mosby
Co., 1968, vol. 2, pp. 1345-1371.

Self-Evaluation Quiz

1. The peripheral receptive field changes after a laceration.

a) ‘True
b) False
2. A sénsory reeducation program is designed specifically for
the elderly.
a) True
b) False
3. The A-beta nerve fibers are responsible for the perception of
touch.
a) True
b) False
4. Testing with a pin prick to determine if pain is present is
not necessary, since the perception of vibration tested with
the 30 cps (hertz) tuning fork follows perception of pain.
a) True
b) False
5. Testing and training may be done easily in an open clinic
area.
a) True
b) False
t’s vision be
6. It is of paramount importance that the patien
eliminated during the training proced ure.
Alec
b) False
r better func-
7. Late-phase reeducation is designed to recove
tional sensation in the hand.
a) True
b) False
will alleviate the
8. Sensory reeducation on a painful hand
pain.
 130 E. J. MACKIN

a) True
b) False
9. Three correct responses out of ten are essential for a true
two-point discrimination.
a) True
b) False
10. Fingers must be able ‘“‘to see,’ that is, they must have a
visual quality without the assistance of the eye.
a) True
b) False

Answers on page 527.

 Management of Edema
Shellye Bittinger, O.T.R.

Objective

The purpose of this paper is to discuss the complication

of edema in the hand as a management problem, to be
considered in three phases of treatment. Specific treatment
techniques and precautions characterize each of these
phases. The paper will also briefly discuss various treatment
modalities utilized in the postoperative phase of an edema
réduction program.

Certainly one of the most common and most challenging

of edema.
aspects of hand rehabilitation is the management
of fluid in cells,
Edema, an accumulation of excessive amounts
reactio n to physica l
tissues or serous cavities, is a physiologic
as a contami nated
injury, produced by such varied woundings
field or the
open-fracture dislocation incurred on a football
“sterile”? wound of elective surgery.
the fact that
Both literature and clinical practice document
signif icantl y limits joint
edema delays healing, causes pain and
omise d funct ional abilities
mobility, thus contributing to compr
ced in a norma l, healthy
and dependency. Edema can be produ
positi on for a few hours.
limb by immobilization in a dependent
the exagg erati on of this
We can thus further appreciate ,
ated with a physic al injury
iatrogenic condition when it is associ
disease or prolonged immobilization.
learned by observing
The management of edema can be
ent circulatory system on
active, uninjured individuals. The affer
contr olled by arterial blood
the volar surface of the hand is
dorsum of the hand, is
pressure. Efferent flow, on the
atic systems. In order for
maintained by the venous and lymph

Department, North
pational Therapy
Shellye Bittinger, O.T.R., Occu
Hospi tal, Chap el Hill, N.C.
Carolina Memorial

131
132 S. BITTINGER

the “return flow’? mechanisms to work, active muscle contrac-

tion and joint motion are mandatory.
It is imperative that those treating hand injuries appreciate
and thoroughly understand the intricate anatomy and kinesiol-
ogy. The closely fitted, movable structures in the hand, and
especially those in the fingers, have little tolerance for increased
volume. Any alteration in the joint integrity or consistency of
the soft tissue surrounding them will limit motion.
The hand, though, is not a separate entity, divorced from
the rest of the body as a sensate, movable part. The hand is
one’s occupation, an extension of personality, a means of
communication. Therefore, a team effort is essential in the
management of edema. That team includes, at minimum, the
patient and the surgeon. Ideally, it should also consist of the
family, therapist and nursing staff.
Dr. James Hunter, in his article “Salvage of the Burned
Hand” said, “The prevention and treatment of edema is of
paramount importance during all phases of management of the
injured hand” [1].
Three distinct phases of an edema control program should
be considered for surgical candidates. These are the preopera-
tive, intraoperative and posteroperative phases. Preoperative
management includes patient education and baseline measure-
ments. The patient needs to understand his role as part of the
team in order to accept his part of the responsibility for the
outcome. That role may include a preoperative exercise
program (Fig. 1), skin care and positioning techniques. The
postoperative rehabilitation program should also be explained
and agreed upon, i.e. length of hospitalization and frequency of
postoperative visits. At our hand clinic we make a “contract”
with the patient to ensure a bilateral commitment and thereby
minimize misunderstandings. Baseline measurements are essen-
tial in most procedures and may include those pertinent studies
needed for comparative results. Many or all of the following
may be relevant: functional evaluation, range of motion,
volumetric or circumferential measurements, sensory or voca-
tional testing, manual muscle tests, grip and pinch strengths.
The intraoperative phase includes élevation of the affected
limb during the operation, generally positioned on a hand table;
?
properly placed incisions; gentle handling of the tissue; and
 ‘weigoid astotaxe eayesedoalg “T “Ola
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134 S. BITTINGER

adequate hemostasis. Prompt tourniquet removal from the arm

is essential; the tourniquet is released in order to avoid the
venous tourniquet effect when left in place. This venous
strangling is thought to contribute significantly to the increased
postoperative edema volume due to arterial pooling. An
immediate compressive but unrestrictive dressing (Fig. 2),
meticulously applied, decreases further the potential for wound
edema [2].
The postoperative phase commences in the recovery room
with the involved extremity positioned and supported in
elevation. A commercial hand bag may be utilized to accom-
plish this task, but nursing personnel must understand the need
for avoiding proximal constricting elements of these devices.
The ward personnel then perform frequent postoperative
vascular and neurological checks to discover quickly the
possible complications of an excessively tight splint or dressing.
Both the patient and ward personnel should be aware of the
effects of anesthesia, particularly if a ‘nerve block’’ has been

i iat be
FIG. 2. (A) Compressive dressing. (B) Unrestrictive dressing.
MANAGEMENT OF EDEMA 135

performed. The patient who has a good understanding of what

to expect is more likely to be cooperative. The patient begins
active motion of his unaffected joints when appropriate, usually
in a few hours after surgery. At this time a structured hand
rehabilitation program may begin [3].
Throughout the first few postoperative days, the involved
hand should be positioned in elevation [4, 5] above the heart
whether the patient is supine, sitting or ambulating. The patient
should be encouraged to perform his normal activities of daily
living, i.e. feeding, grooming and dressing, as well as ambulation.
Activities can be initiated in elevation in the patient’s bed if
necessary, then modified for home use. The ‘“‘Herring”’ track
(Fig. 3) [6] can be used at bedside to encourage active gross

FIG. 3. Herring track.

 136
S. BITTINGER

‘O14
‘p poydepy ‘syurjds
MANAGEMENT OF EDEMA iss7

motor functioning of the affected extremity. It can be modified

to accommodate bulky hand dressings.
After discharge and suture removal, when the incisions are
well-healed, the following therapeutic techniques may be
utilized to reduce or control edema: paraffin baths, massage
[7], Isotoner gloves [8], string wrapping [2, 9] and whirlpool.
Splinting (Fig. 4), assistive devices and a planned exercise
program may be incorporated at any time it is appropriate
postoperatively. The key to success in combatting postoperative
edema is early active motion and elevation above the heart.
Other techniques which may be of value are the Jobst
intermittent compression unit, joint mobilization as described
by Mennell [10] and a biofeedback machine. However, my
philosophy of hand rehabilitation is that the patient, to a great
degree, should be his own therapist. In order for the patient
realistically to integrate his hand rehabilitation program into his
lifestyle, it must be simple, effective and easy to follow.
In summary, uncontrolled edema may produce not only a
process,
nonfunctional extremity, but also a long rehabilitation
possible litigation and difficult vocation al placeme nt. It often
disabilit y. Edema can be
leads to despair and psychological
present, is not a simple
avoided, but its management, once
t of one’s attentio n, its
matter. If edema is kept at the forefron
can be minimiz ed.
presence as a significant complication

References

hand. Surg. Clin. North Am. 47

1. Hunter, J.M.: Salvage of the burned
(5):1060-1061, 1967.
and bandaging. Jn Hunter,
2. Hunter, J.M. and Mackin, E.J.. Edema
(eds.): Rehabi litation of the Hand. St.
Schneider, Mackin and Bell
C. V. Mosby Co., 1978, pp. ea 3=1 242
Louis:
litation following hand injury.
3. Weber, F.R. and Davis, J.: Rehabi
. Clin. North Am. 9 (2):52 9-542, 1978.
Orthop
ion crutch in the treatment of the
4. Brown, D.M. and Clark, S.: Elevat
32 (5):320-321, 1978.
edematous hand. Am. J. Occup. Ther.
swolle n hand. Physi otherapy 63 (9):285-286,
5. Nicholas, J.S.: The
Ons
table Exercise Track Manual. Cleve-
6. Herring, M.: The Herring Adjus
land, Ohio:Cleo Living Aids, 1970.
Krusen, F.H.: Handbook of Physical
7. Knapp, M.E.: Massage. In
2. Phila delphia:W. B. Saunders Co.,
Medicine and Rehabilitation, ed.
1971, pp. 382-384.
 138 S. BITTINGER

8. Perry, J.F.: Use of a surgical glove in treatment of edema in the hand.

J. Am. Phys. Ther. Assoc. 54 (5):498-499, 1974.
9. Shaw, R.C.: Elastic paper wrapping for compression of a swollen
finger. Plast. Reconstr. Surg. 62 (2):304, 1978.
10. Mennell, J.M.: Joint Pain: Diagnosis and Treatment Using Manipu-
lative Techniques. Boston:Little, Brown and Co., 1964.

Self-Evaluation Quiz

1. Edema can occur as a result of:

a) Surgical procedure
b) Sport injury
c) Immobilization in a dependent position
d) Infection, secondary to a physical insult
e) All of the above
2. Daily functional activity performance can be significantly
limited by the presence of edema, especially in the hand.
a) True
b) False
3. Both active muscle contraction and joint motion are
essential for good circulatory exchange in the prevention of
edema.
a) True
b) False
Match the characteristics of the right column with the
specific program phase in the left column.
—____ 4. Preoperative a) Prompt tourniquet removal
—___. 5._ Intraoperative b) Baseline measurements
—— 6. Postoperative c) Elevation of affected extremity
d) Compressive but unrestrictive dressing
7. The most important factor in decreasing edema immediately
postoperatively in the affected hand is:
a) Immediate active motion of the uninvolved extremity
b) Frequent vascular/neurological checks
c) Involved extremity positioned in elevation above the
* heart
d) A planned exercise program
8. Routine activities of daily living should be initiated only
after discharge from the hospital, upon suture removal and
when the incisions are well healed.
a) True
b) False
MANAGEMENT OF EDEMA 139

9: A postoperative hand rehabilitation program may consist

of:
a) Paraffin baths to the affected hand, in elevation
b) Traditional massage to decrease, minimize adhesions
c) Isotoner or other elasticized gloves to reduce edema
d) Splinting/assistive devices
e) All of the above
10. A patient who has a clear understanding of what to expect
from the surgical procedure preoperatively is more likely to
be cooperative postoperatively.
a) True
b) False
iy: The venous and lymphatic systems are responsible for
afferent blood flow.
a) True
b) False
12. The Herring track can be used bedside to encourage active
gross motor functioning.
a) True
b) False

Answers on page 527.

 Panel:
Traumatic Hand Problems
 Discussion:
Traumatic Hand Problems

Moderator: J. Leonard Goldner, M.D.

Panelists: F. William Bora, Jr., M.D.
J. Joseph Danyo, M.D.
Joseph Imbriglia, M.D.
Thomas J. Krizek, M.D.
Peter Linton, M.D.
Evelyn J. Mackin, L.P.T.

Moderator: We will now have a panel discussion on

traumatic hand problems . I shall paint a hypothetical picture
and then ask the panelists how they would manage the case and
why. We would like some conflicti ng opinions among the panel
members.
The first patient is a 28-year-old highway patrolman. He was
at
involved in an alteraction with an individual who shot him
through the patrolm an’s right
close range. The bullet went
The bullet
index finger. He is right-handed. He carries a gun.
artery, contuse d the nerve and
injured the skin and the digital
of the proxima l phalanx and part
blew out the lateral condyle
Thus, he had bone loss, essentia lly of
of the collateral ligament.
l phalanx . He had a satisfac tory
the distal end of the proxima
nerve was good; one was contuse d. One
flexor tendon. One
nonfunc tional. The size of the wound,
vessel was good; one was
— about the size of
being at close range, was about 2 X 3 cm
room, what would be
quarter. If you saw him in the emergency
your plan of treatment, Dr. Linton?
is.
Dr. Linton*: I am not sure what level this
is right at the level of the proximal
Moderator: This
.
interphalangeal joint of the right index finger

of Vermont.
*Chief of Plastic Surgery at the University

143
144 DISCUSSION

Dr. Linton: So he has the structures on the other side of the

finger, but has lost basically everything on the radial side.
Moderator: Yes, the condyle, skin and lateral band. The
flexor tendon is good; the nerve is contused but satisfactory.
Dr. Linton: What kind of gun was used? It is important to
know whether this was a low-velocity or a high-velocity gun.
Moderator: It was at close range, and anything is high-
velocity at close range. I think that question is a two-edged
sword. If you shoot a .22 at someone’s thigh, it shatters the
femur; that is a lot of damage, which means high velocity.
Dr. Linton: This patient would probably be a candidate for
an amputation. Otherwise, he would have, at best, a stiff
proximal interphalangeal joint and would require some kind of
resensitizing procedure to the radial side of the index finger. If
you did an amputation distally, you would end up with a short
stump. That might be possible. You might be able to make a
short stump that would be useful by preserving a little bit of
length and bringing the ulnar-side sensible skin over to cover it.
You might very likely end up with a ray amputation. I would
probably complete the amputation at the PIP joint level, use the
ulnar pedicle skin to cover it loosely, and then see subsequently
whether a ray amputation would be useful to him, depending
upon what the requirements for his hand were.
Moderator: I will not tell you what was done in this case, of
course, but I will tell you that the various possibilities were
discussed with him. He said, ‘“‘Well, Doctor, if I lose part of my
finger, I lose my job. I cannot stay out on the highway any
more. I cannot handle a gun if I do not have my index finger.”
Then, of course, the next question was, ‘“How good does your
index finger have to be?”’ He answered, ‘‘Good enough to shoot
a gun.” I asked, “‘Can you not work in the office?’ He said,
‘““No, because I am not high enough in rank and I do not have
enough seniority. I am either in or out. I like my work. I want
to stay on the job.”’ So, Dr. Imbriglia, what is the next move?
Dr. Imbriglia: You said one nerve was contused and one was
intact; so I assume his distal sensation would be okay
eventually. The critical thing is how much of the condyle is
gone in the proximal interphalangeal joint — if, as I assume,
both the flexor and extensor tendons are intact.
Moderator: They are intact, except for the lateral band; the
oblique fibers are not, but the major tendons are intact and
salvageable.
TRAUMATIC HAND PROBLEMS 145

Dr. Imbriglia: Then the critical factor is, how much of the
condyle is gone?
Moderator: At least 50% of it cannot be saved.
Dr. Imbriglia: If it is 50%, I would say that there is no way
to save the joint or to regain stability. In this case, I would
remove the cartilage from the other side of the joint and do a
primary arthrodesis.
Moderator: I told him that we might have to arthrodese the
joint, depending upon what it looked like, and he said, “No,
you can’t do that, because I cannot pull the trigger without that
middle joint moving.’ I asked if he would want to go to
vocational rehabilitation. He said, ‘‘“No, I want to keep my job.”
So, Dr. Krizek, what do you do now?
Dr. Krizek*: I would not consider amputation under any
circumstances on the basis of what I have heard. The only thing
that is ndét going to move is his proximal interphalangeal joint
and that may just be temporary. It is not the end of the world.
He can shoot his gun with his other hand. But the critical
problem here is to get skin coverage, to get the wound healed.
You have plenty of time to decide what to do next.
Moderator: So you say, “We will not amputate it and we
will not fuse it. We will dress it.” Do you want to close it
primarily? Do you want to wait five days? Or what do you want
to do, Dr. Krizek?
Dr. Krizek: I would take exception to trying to use a skin
graft. You have bone, joint and nerve exposed. If there were
ever an indication for putting flap coverage on, this would be ate
I am just trying to decide whether I can get enough off the
dorsum of the hand.
Moderator: I stated that it was the size of a 25-cent piece.
Dr. Krizek: Yes, you did.
ly
Moderator: And the finger is swollen. It was at relative
e withou t
close range. But this is a difficult thing to visualiz
pictures.
the middle
Dr. Krizek: Well, it does not have to be done in
fan of biologic
of the night; I agree with you there. I am a great
of amnion in our
dressings such as pigskin, and we have jars full
hospital, which I would dress on the wound.
add to that?
Modrator: Dr. Danyo, do you have anything to

of Plastic Surgery Service, Columbia

*Professor of Surgery, Chief
Presbyterian Medical Center.
146 DISCUSSION

Dr. Danyo: Yes, I would echo Dr. Krizek’s thoughts. I

would ligate the ulnar digital artery, clean up the wound, put in
iodoform gauze, apply a bulky dressing and, a few days later,
reassess the situation. I might consider an abdominal or a
pectoral pedicle graft. To maintain motion, at a later date, I
would use a silicone implant to try to give him function at the
proximal interphalangeal joint.
Moderator: By a later date, would you mean, for instance,
two weeks or depending upon skin coverage?
Dr. Danyo: No, there is no hurry; I would wait several
months. A radial collateral ligament is attached. He could have
an orthosis made with a small hinge to support him, to prevent
him from radially deviating the proximal interphalangeal joint.
He could function.
Moderator: Now I shall tell you what we did in this case. We
went through this conversation. We did take him to the
operating room. We excised his wound, irrigated it and put a
Betadine gauze dressing on it. In five days he had enough
granulation tissue; so I did put a full-thickness graft from his
groin, defatted, on the indentation, which was 99.5% successful.
After about 2% weeks, we arranged a little molded aluminum
splint which held his index finger toward the ulnar side, and we
gave him a whole bag full of splints. We started him exercising.
He stayed on the job, however, in the office because he could
do that temporarily. Then, at eight weeks, the edema had gone
down, much of his sensation had returned from his neuropraxia,
and his circulation was excellent through his ulnar digital artery.
He had good local flow. At that point, I just excised the skin
graft and mobilized the skin proximally, distally and then
closed it. Of course, you would not have any way of knowing
that without seeing a picture, but it was possible to use the skin
in his finger. At the same time, I resected the rest of his
condyle, which gave us about 6 mm of shortening, and that
allowed us to pull the skin together. Then we went on to the
arthroplasty program, with the volar capsule in this joint. We
then had a volar capsuloplasty, a closed joint, and we kept him
on this program for another three months. He regained about
30° of motion but his digit was unstable. He did not have
enough stability to maintain radial-ulnar alignment. We then
went ahead with a silicone-Dacron prosthesis, which was put in
TRAUMATIC HAND PROBLEMS 147

roughly five months after his injury. We started moving that at

about five days. There was adequate skin to cover it. It has been
six years now. He is working. He is shooting his gun and has a
good record on the target practice range. He is very careful on
the highway when he confronts anyone at close range. He pulls
his gun first and questions second. He says that the last time he
followed the rule that he should not pull his gun until he has
some kind of suspicion, but now he puts his hand on his gun
and gets ready, with his index finger around the trigger. So this
is one approach to the problem. I think that the use of implants
in individuals who have repetitive trauma still has a place. We
have used the interphalangeal joint prosthesis quite a few times.
Sometimes it breaks; sometimes it has to be replaced. But there
is a place for it.
The second patient works in a metal mill. He works around
sharp knives and repetitive motions are required. He is
right-handed. His left hand was caught in the teeth of a knife. It
thirds
shaved off the skin, the extensor tendons, the upper two
s, the sagittal
of his metacarpal heads, all the collateral ligament
distal
bands, everything right down to bone out to about the
about wrist level. He
end of the proximal phalanges, starting at
n in his fingers
comes to the emergency room with good sensatio
pain. Every-
on the flexor surface, good circulation, minimal
skin from the second
thing is wide open. He has in fact lost
you like to comment
metacarpal to the fifth metacarpal. Would
on this?
tissue cover
Comment: It looks like his basic loss is a soft
plus extensor function.
the
Moderator: Skin, extensor tendons, two thirds of
on extens ors, all the way down
metacarpal head and the comm
to bone.
de this with a
Comment: I think I would probably provi
pedicle flap cover.
?
Moderator: Would you do it that same night
No, I would cover it with a dressing and
Comment:
probably do it the next day.
do?
Moderator: Dr. Bora, what would you
that. As I unde rstand it, this is an
Dr. Bora: I agree with
langeal joint injury, is that
extensor tendon and metacarpopha
that were missing and for
right? These are the two structures
coverage.
future management we must have flap
 DISCUSSION
148

Moderator: Two thirds of the metacarpal heads are gone.

The lower flexor surface is still intact. He has the space; that is,
it has not shrunk, but he does not have any articular surface. On
extension, he comes to about —20° to-30° and then his
proximal phalanx abuts on raw bone.
Dr. Bora: So the basic responsibility would be to get
coverage good enough so that in the future you can put in
extensor tendon grafts and perhaps joints to give him some
motion.
Moderator: From an anatomic standpoint, he will need a
dorsal hood, extensor tendons and something to his metacarpal
heads. Dr. Danyo, what about the type of flap and when would
you do it?
Dr. Danyo: Fortunately, I have not had too many cases like
that, but I have had three or four from industrial accidents. If
the wound is clean and if the time of day is reasonable, I have
gone ahead and done a primary abdominal pedicle graft. If the
wound could not be made clean, I have debrided it, packed it
and then a few days later brought the patient back in for a
delayed primary abdominal pedicle graft. I have stopped doing
primary articifial tendon replacement at the time of abdominal
pedicle graft because two of these got infected. I do not know
whether it was related to their being done primarily, but at any
rate now I would do coverage after a few days and later on,
after the graft is healed, do the tendon replacement. In the
meantime, the patient is passively using it, appropriately
splinted, with the metacarpophalangeal joints in flexion. Then
eight weeks later I would do the tendon grafts.
Moderator: Just for clarification, there is nothing to put the
tendon grafts into. You have just this raw bone. So we are going
to get the flap on. Dr. Danyo has described an abdominal
pedicle graft. What area of the abdomen would you take this
from, Dr. Danyo? Would you take it from the lateral on the
same side? Would you take it periumbilically? Would you take
it from the groin?
Dr. Danyo: I would take it from the left lower quadrant.
Moderator: Left lower quadrant and the superficial epi-
gastric artery, is that what you would use?
Dr. Danyo: Yes, that is correct.
Moderator: So this would be a lower abdominal flap.
TRAUMATIC HAND PROBLEMS 149

Dr. Danyo: Is he right-handed?

Moderator: The injury is to the left hand, and he is
right-handed. He weighs 146 pounds. He does not have a large
abdomen. He can reach around his abdomen. Sometimes, that
makes a big difference. If he were left-handed, would you put it
on the left side or the right side?
Dr. Danyo: On the right side, depending on the individual.
Moderator: Dr. Krizek, what would you do?
Dr. Krizek: It should be possible to transfer flaps to the
back of the hand that literally have no fat attached to them at
all. The groin flap has now been described as an axial flap going
out on the superficial circumflex iliac. You can take the tissue
off right about the anterior iliac crest. It is thin and has
essentially no fat. It has a proximal area 6 inches long; so you
can attach it from either side. The subclavicular region with the
deltoid pectoral flap is also an area that has essentially no fat
underneath it. The arm is also a marvelous donor site. | am
actually glad to see less frequent use of the standard abdominal
flap, because it is fat and is always designed in a circle for some
reason so that when the wound contracts a little, it looks as if
you stuck your hand into a hamburger bun.
Moderator: Dr. Linton, would you like to enlarge on that?
Dr. Linton: No, not really, but Dr. Krizek has made a very
important point that bears repeating. The territory of the
circumflex iliac vessel extends considerably farther laterally
than we ever thought. The standard low inferiorly based
abdominal flap is a big, fat, ugly flap. There is just no way to
get around it. But if you use the territory laterally it is still an
axial-pattern flap. It is much better skin. It is thinner. Also, the
donor site falls into the area which can normally be covered by
a bathing suit.
so
Dr. Krizek: And the donor site can be closed primarily;
there is no need for a split-thickness graft.
flex
Moderator: How do you determine where the circum
vessel is located?
inguinal
Dr. Krizek: It runs parallel and just above the
just beyond the iliac
ligament. You can see it. It starts laterally
crest and follows medially.
, from one
Moderator: There is a great variation, though
have a very large one; some have a
person to another. Some
150 DISCUSSION

medium-sized one. In some it has two branches. We usually

depend on the Doppler, and you can pick up its course pretty
well and follow it along. During the course of the elevation, you
can actually clamp the vessel off and see changes that might
occur in the flap.
So, we have decided that he needs a flap. I agree with Dr.
Krizek. We want a free flap or a pedicle flap. Dr. Imbriglia, have
you had any experience with free flaps that are done at one
stage and taken from the donor site and put on the part?
Dr. Imbriglia: No, in this situation, I would certainly stick
with the pedicle flap. I have never done a free flap to the back
of the hand in this situation.
Moderator: Does anyone have any experience with free
flaps?
Dr. Krizek: Certainly, if you are well equipped and have a
team with enough competence, then do a free flap. It is a
one-stage maneuver. Otherwise, the groin flap of McGregor is
the one to be used. In most people’s hands, free flaps now have
a success rate in excess of 95%, which is not something for
which one should apologize.
Moderator: We have a team that can handle free flaps in this
instance, I suppose for two reasons: first, we thought it would
be appropriate; second, the challenge is there. It is an eight-hour
procedure.
A free flap was put on this patient, using the dorsal branch
of the brachial artery. But you have to do an arteriogram. You
could pick up an artery at the elbow, which is of quite good
size. Then an end-to-side anastomosis would be done. Of course,
one might say there is risk. On the radial side, you could pick
up a branch of the artery and, in addition, on the ulnar side the
collateral artery was still intact; so there was not much of a risk.
He had a large groin flap put on primarily. The wound was
closed initially. The flap took. There were a few problems with
a little bleeding because we used heparin, but that was all right.
There was a little blueness which required special care, but that
was resolved. The flap was successful. He stayed in the hospital
for about eight days, as compared to a little longer if he had had
the groin flap.
Question: What was the level of the anastomosis?
Moderator: It was at about the wrist level, to the radial
artery, end-to-side. He had good flow below.
TRAUMATIC HAND PROBLEMS ilsyil

Dr. Linton: For the sake of discussion, was any considera-

tion given to a dorsalis pedis free flap, taking all the extensor
tendons from the foot at the same time in order to provide a
vascularized tendon graft with a pedicle of skin overlying it, and
doing it all at one time except for the joints?
Moderator: As a matter of fact, there was. We have done
some foot-to-hand flaps for various regions with the cutaneous
nerves. But we occasionally run into a problem with the foot.
The more material you take off the top of the foot, the more
the toes become edematous. We felt that, in this instance, we
probably could spare the groin better than the foot. A small
flap between the great and second toe, I think, can be tolerated;
but with the whole top of the foot, which is what this would
have taken, I think this man would have been jeopardized in his
work. Is this the general feeling about toe flaps among the
members of the panel?
Dr. Linton: I have never done a dorsalis pedis flap; so I
cannot speak from any experience at all, except that recently I
was at Rollin Daniel’s symposium in Montreal, Quebec, and I
can bring some fresh words from them. Harry Bunke and others
reported the experience of all those people, probably a few
hundred, who are doing dorsalis pedis flaps. Most surgeons are
having some problems with their donor site in terms of healing
of the skin graft. Splinting or casting is required; so there is no
|
motion of the foot. Even so, it is an extensive donor site.
think that is a very important concept.
Moderator: I have a great respect for the foot, and I do not
rob it readily. But we got this flap on and it is secured.
And now, Ms. Mackin, would you tell us about keeping
those joints moving? The metacarpophalangeal joints, two
We
thirds of the articular surface and the extensors are gone.
flap was put on
have to maintain good flexion. Incidentally, the
so that we would
with the metacarpophalangeal joints flexed
stage by
not be robbing ourselves when we came to the next
having a flap that was too tight.
would fit
Ms. Mackin: I think that, as soon as possible, we
with dynamic
the patient with a dorsal forearm-based splint
rpophalangeal
outrigger to maintain extension of the metaca
The splint could
joint and allow flexion of the same joint.
t compression were
extend over the flap if precautions to preven
taken.
 DISCUSSION
a,

Moderator: Three weeks after the flap was on we would not

have any compression. He was put in an outrigger, which was
proximal to his wrist to bring him up to neutral. But we did not
want it pressing on the flap. Since he had good sensation, it was
no problem. Then we had a Velcro strap type of thing. We
put some little clips in his fingernails so the fingers could be
pulled down into flexion. The important thing was to splint the
proximal interphalangeal joints during flexion so that he would
not flex his proximal interphalangeal joints but only his
metacarpophalangeal joints. Do you want to emphasize that
point — about when you are pulling down on the fingers, how
you stop the proximal interphalangeal joints from bending and
get your force on the metacarpophalangeal joints?
Ms. Mackin: If the force of flexion, either active or passive,
is occurring at the proximal interphalangeal joint, it may be
necesssary to ensure metacarpophalangeal flexion by applying
removable cylinder casts or taped-on Zimmer splints over the
proximal interphalangeal joint. This will concentrate the force
at the metacarpophalangeal joint.
Moderator: We want to pull his metacarpophalangeal joints
down. His proximal interphalangeal joints work well. If we put
little buttonhooks on his fingernails with some kind of glue and
you pull on them, they flex the proximal interphalangeal joints
down to 100°, and his metacarpophalangeal joints do not move;
so we put a dorsal aluminum split on the proximal inter-
phalangeal joints and then pull down. It works on his
metacarpophalangeal joints. So this keeps the thing moving.
Ms. Mackin: It is the same idea as with the arthroplasty,
when you are trying to get the force at the metacarpophalangeal
joint.
Moderator: Yes, that is right; the same thing.
Now we have to do his joints, Dr. Bora. We have decided
that we really cannot save what he has left. That is, he has a few
degrees of flexion, but he does not do well in extension. He is
developing arthrofibrosis. He cannot come up too well. Do you
have a choice? Do you want a resection arthroplasty? Or do you
want to put a prosthesis in? Or do you want to fuse him?
Dr. Bora: Before you do anything, if you are thinking in
terms of arthroplasty, you have to have motors to move the
arthroplasty. As I understand it, this man does not have any
extensor tendons.
TRAUMATIC HAND PROBLEMS live

Moderator: Yes, that is correct.

Dr. Bora: I think that is what I would direct my attention
to, first. Yes, I would go for motion in this patient. He lost two
thirds of his metacarpophalangeal joints. Are his proximal
phalanges okay?
Moderator: Yes, they are good.
Dr. Bora: Then the next thing to do is to give him active
extension. What is the defect in his extensor tendon?
Moderator: It is gone. There is no extensor tendon. It is lost
back to the transverse retinaculum on the dorsum and out to
the proximal end of the proximal phalanx in the midhalf. He
has a tendon there, but there is no hood.
Dr. Bora: You still have to give him active extension.
Moderator: Yes, that is right.
Dr. Bora: That means you either think in terms of tendon
transfers plus graft or you graft him to the motor that he has.
Moderator: The big question is, how do you replace the
dorsal hood when it is gone with its extensor tendon? We agree
that we are going to try to maintain motion.
Dr. Bora: I think it would be very difficult to replace the
hood.
Moderator: That is exactly the right answer. You have seen
the extensor in rheumatoids. You have seen what it does when
it shifts back and forth. It is useless. It acts as a flexor or
deviator but it really does not have good extensor power.
In this case we took a piece of fascia lata, as large a square
as the top of his hand, and made slits in it, making it look like a
many-thonged piece of leather goods. We hooked each thong to
the sides so that they would go into the sagittal bands and into
the volar side. We did this on all four digits. We tapered the
proximal end back so we could hook the extensor tendons into
but it
this. That is not enough to pull his fingers up completely,
gave us a start. Then we took the second and third toe extensors
we
and made some little belt-buckle cuffs in the extensor. So
little nick
had the tendon going over the joint and through a
of his
that we made and then out into the rim of the extensor
it into the
finger. Now we could guide it back and hook
and made a
proprius and the communis. Next we went across
little loop for each tendon.
Question: Did you do that all at once?
Moderator: Yes, that is, the flap.
Loy! DISCUSSION

Question: It was not staged, was it?

Moderator: No, the fascia lata and the toe extensors were
done simultaneously. We had one team taking the tendons, one
working on the hand and another working on the thigh. This
was done in about three hours. We put him up in extension with
the appropriate tension. We put it in slightly on the tight side.
We figured we could stretch easier than we could gain lack of
tension, which in my experience in tendon work is always true.
If you have to err, err on the tight side rather than on the loose
side.
A year and a half postoperatively, the patient has extension
to about 70° and can flex to 90°. His proximal interphalangeal
joints work very well, because his lateral bands were still intact.
His joints are beginning to bother him. He aches. He has some
weakness with extensive grip. He has a grip of about 40 pounds.
He is able to work, but I think one of these days we are going to
be faced with either allografts of the metacarpal heads or
prosthetic replacements.
Does anyone have any experience with allografts in the
hand?
Comment: I have with the radius but not the hand.
Comment: No, not with allografts, but autografts.
Moderator: Allografts; in other words, take it from a
cadaver, glycerinize it and, let us say, use the metacarpal heads
or shafts for it. We have not done it for metacarpals, but we
have dene it for almost all other bones now. They work
reasonably well. We would not hesitate, if we had four
metacarpals in a young person, let us say, with half the shaft
gone, to take allografts from a cadaver, glycerinize them and try
to reconstruct the joint with collateral ligaments. This would be
preferable to prostheses in a young person. We have several
patients with prostheses after trauma. They all have fractured,
but these are normal hands otherwise and are still functioning.
Prostheses are acting sort of as fillers and doing reasonably well,
but they are not ideal.
The last case involves a diabetic. A woman comes to the
office with a swollen palm of the hand. She has had no obvious
injury, but there is a fusiform swelling from the tip of her finger
to the transverse crease in the palm. This has occurred during
the past 48 hours. She says that the pain is excruciating. She
TRAUMATIC HAND PROBLEMS 155

cannot sleep. She cannot move her hand. She will not allow you
to touch it. When you ask her to flex the tip, she screams. When
you attempt to move it passively, she screams. The digit is hot.
Her white count is 18,000, with a shift to the left. Her diabetes
is out of control. Does anyone want to respond to that?
Dr. Krizek: If you culture bacteria in test tubes and add a
lot of sugar, the gram-negative organisms will not grow. With a
gram-negative infection, the blood sugar always drops. In
individuals with Pseudomonas burn sepsis, the blood sugar will
often be around 20 or 30 mg%. That is why people in
gram-negative shock look as if they have had too much insulin.
You have described a situation in a diabetic; when you say “out
of control,”’ do you mean the blood sugar has gone up?
Moderator: Yes, that is correct.
Dr. Krizek: I would wager that you are dealing with a
gram-positive organism, probably Staphylococcus. That gives
you a clue as to what antibiotic you might want to use.
Moderator: Dr. Krizek’s detective work is very good,
because this was a Staphylococcus aureus infection. It probably
was seeded from her teeth, which were bad. I think this was a
septicemia. The next question is, what do we do about this?
Dr. Imbriglia: We open it up wide.
Moderator: Would you use a lateral incision or a volar
incision, Dr. Imbriglia?
Dr. Imbriglia: I would use an oblique zig-zag volar incision
and probably one transverse incision in the palm. I would open
the sheath and drain it.
Moderator: So you would have incisions at right angles to
the finger?
Dr. Imbriglia: Actually at 45°. I do not connect the area
over the proximal interphalangeal joint.
Moderator: Do you open the cruciate part of ibe
Dr. Imbriglia: Yes, I do.
Moderator: What kind of a catheter do you put in?
ed up
Dr. Imbriglia: A small polyethylene catheter thread
from proximal to distal.
particular
Moderator: Let me tell you what happened in this
case. She was taken to the operating room ...
went to
Dr. Krizek: I had my hand up before you said you
to be the single voice of polite
the operating room. I was going
156 DISCUSSION

dissent, suggesting that this woman’s problem is not as much of

a surgical emergency as we might imagine. She is a diabetic out
of control. A little time spent getting her in order there,
splinting the hand, should be beneficial. I believe the absolute
sine qua non in treating infection is to immobilize everything,
even in plaster, and with elevation. In another 12 hours, you
might have a very good idea of where you can drain. Paul Brand
has made a good point about that: you will know exactly then,
rather than laying the whole hand open on a fishing expedition.
Moderator: This point is well taken. If this is a trauma, with
cellulitis, the question arises, is this a tendon sheath infection or
not? That is exactly what would have happened. It would have
gone to the patient care unit, with elevation and high doses of
antibiotics that might affect gram-positive and gram-negative
organisms. But in this instance, the woman had a very discrete
localization. It was not broken through. There was no question
that the whole tendon sheath was faulty. I agree completely
that the patient should be in the best shape possible. But we felt
that this would be a very short procedure. In diabetics, my
experience has been that the best way to get them into good
shape is to drain their abscesses. With that in mind, we took her
to the operating room, but not for a brachial block. I did not
want any needles punched anywhere on this patient except for
her fluids. We gave her a quick general physical examination.
Then we made the three incisions as you described: one in the
palm, one at the base and one at the tip. We expressed 50 cc of
bloody pus, which on direct smear showed gram-positive
organisms that cultured out Staphylococcus coagulase-positive.
We put a soft silicone tube in, rather than a polyethylene tube;
so there was no pressure from it at all. We started her on a drip.
Within 24 hours, her temperature was down, we had better
control and her pain was relieved. In about five days, much of
the swelling was gone and she could flex about 30°. One year
later, she can now flex 60°. She has a great deal of damage in
that finger. The tendons are adherent. But she still has her
finger, which has been the exception, since most diabetics with
finger infections lose them. So it is a critical injury. I think it
has to be treated quickly and thoroughly. The question is,
should you open the whole thing, lay it wide open, or treat it
this way? Our experience has been that we have a greater
TRAUMATIC HAND PROBLEMS kaye!

chance of saving the finger if we do multiple incisions and save

the annular ligaments, than if we open everything up. The
reason is that you get good drainage in that way. What you are
trying to do is to decrease the pressure and save the blood
supply to tendons, or at least what is there.
Does anyone have any further comments or questions about
this problem?
Question: What was the drip?
Moderator: The drip was neomycin-bacitracin in a very low
concentration.
Dr. Krizek: Why did you use neomycin for Staphylococcus
aureus?
Moderator: She had a sensitivity to penicillin. We were not
certain what our gram-negative organisms were until the
following day. As soon as we found that out, we changed to a
synthetic. She was given methicillin and Keflin, because she
turned out to have a bladder infection as well.
Dr. Krizek: With all due respect to Sylvester Carter and the
tubes draining tendon sheaths, I am not persuaded from what |
know about bacteriology and tissue reaction to infection that
delivery of antibiotics into the tendon sheath by that route is
any more effective than trying to deliver antibiotics to the
peritoneal cavity by inserting a small polyethylene catheter,
particularly with an aerobic organism like Staphylococcus
aureus. The finest delivery system of antibiotics that has ever
been invented is the blood stream, and that is probably what
really did the trick.
Moderator: I certainly cannot disagree with that. She got
her high doses intravenously, and really what we should do is
drip fluid into the finger to keep the drainage going, so that you
do not get a fibrin clot.
so
Dr. Imbriglia: I think the important thing here is not
d by the
much the antibiotics as the mechanical drainage provide
fluid.
g
Dr. Linton: Some time ago there was a paper about drippin
seen anythin g
half-strength peroxide through this. I have not
never tried it. Has anyone else tried it?
since. I have
peroxide in
Moderator: If you have ever put half-strength
gums and your
your mouth, you know what it does to your
ne, that was my
tongue. Years ago, when I first went into medici
158 DISCUSSION

first project: what does peroxide do to the mucous membrane

of the rat? It just ruins it.
Comment: Full-strength peroxide kills animals.
Moderator: I have even taken it off of our dressing carriages,
because the first thing the house officer reaches for when he
wants to remove a bloody dressing is 3% or 2% peroxide. It gets
the dressing off all right, but just keep looking at the skin. It
turns white. I do not think peroxide is good for wounds. I
would rather drip 0.75% betadine in. That could even be saline,
for that matter, just to keep the fluid going. Salt water cures a
lot of things.
Congenital Hand Problems
 Radial Club Hand

William H. Bowers, M.D.

Objective
Congenital radial club hand is a convenient term to
differentiate this deformity from the acquired club hand. It
represents a significant upper extremity abnormality which
is associated in high incidence with other congenital
abnormalities. This paper defines, describes and classifies
the deformity. The objective is to relate the proposed
treatment to functional objectives. The author’s personal
plan for managing this deformity is presented.

Definition

Radial club hand is a nonprecise designation of the clinical

deformity resulting from congenital aplasia or hypoplasia of the
radial bony and soft tissue elements of the forearm and
associated elements including and radial to the index ray of the
ive
hand. It was first described in 1733 by Pettit. Other descript
are congenit al aplasia of the radius,
names for this deformity
radial
radial aplasia, congenital club hand, radial clinarthrosis,
hemimelia and radial meromelia.

Etiology
acting
The etiology is obscure. It must be a dysplastic factor
Theorie s include environ -
in the first few weeks of fetal life.
; howeve r, most conside r a
mental and phylogenetic factors
is strong enough to resist
genetic factor more likely. None
reasoned criticism.

Section, Division of Ortho-

William H. Bowers, M.D., Chief, Hand
, Univer sity of North Carolin a School of Medicine, Chapel
paedic Surgery
Hill.

161
162 W. H. BOWERS

Classification

Radial club hand is historically classified according to the

method of Frantz and O’Rahilly. The stem word is hemimelia
which means that one half of a limb is deficit. Hemimelia is
further designated as terminal (no unaffected parts distal to or
in line with the deficient portion) or intercalary (the deficient
portion has proximal and distal portions which are present and
normal). Both terminal and intercalary are further subclassified
into para-axial defects (absence of the tibial or ulnar, or radial
or fibular one half) or transverse defects (total absence distal to
the defect; i.e. both tibia and fibula absent, or both radius and
ulna absent). Applied to the child with the radius absent and a
normal thumb and index finger distally, the defect would be
called a radial hemimelia, intercalary, para-axial (Fig. 1). A
radial club hand in which the radius and the thumb are deficient
would be termed a radial hemimelia, terminal, para-axial (Fig.
2). This classification has some difficulties and has been
superseded by a technical classification proposed by the
International Committee on Prosthetic Research and Develop-
ment. This group uses the stem word meromelia. The deficiency

FIG. 1. Clinical appearance of a radial club hand with thumb present.

RADIAL CLUB HAND 163

FIG. 2. Clinical appearance of a radial club hand with no thumb.

noted in Figure 2 would thus be described as meromelia,

terminal longitudinal, radial.

Clinical Picture

This deformity generally occurs in children of normal

e family
intelligence in whom there is a 10% likelihood of positiv
signifi cant
history. It has a 75% association with other
congeni tal
abnormalities, such as cleft lip/palate, club foot,
genitou rinary
heart disease, and various gastrointestinal and
(1) Holt-Oram syn-
disorders. Major syndromes described are
defect/ventricular
drome (radial club hand plus atrial septal
syndrome (radial
septal defect or cardiac arrhythmias), (2) TAR
manifes t in the first
aplasia plus thrombocytopenia — This is
35% to 40% first-year
few months of life and exhibits a
decreas es with age and
mortality. The severity of the disorder
s.), and (3) Fancon i
surviving adults usually have normal platelet
e anomali es — most
panmyelophthisis (radial aplasia plus multipl
a depress ion of all marrow element s evident at the
significant,
fifth through the tenth year of life).
164 W. H. BOWERS

In addition to a good history and physical examination, a

screening of these patients proposed for surgery should include
chest film, IVP and examination of a peripheral blood smear.
Clinically, the entire upper extremity is usually involved. The
clavicle and humerus may be shorter than the contralateral side
and the scapula smaller. As described by Poland there may be
deficiencies of the pectoral muscles in association with this
deformity. There may be deficient biceps musculature. In
partial absence of the radius there is usually normal elbow
motions, but in complete absence of the radius there may be
restrictions of elbow motion, generally a loss of flexion ability.
In 60% of the children, the deformity is bilateral (although
probably asymmetrical) and is typified by a short, bowed
forearm containing an ulna and variable portions of the radial
element. Complete radial absence is more common than partial.
The carpus is probably volarly dislocated as well as radially
deviated. In spite of this, the wrist has approximately 270° of
circumferential motion, compensating quite well for the absent
pronation and supination of the forearm. The thumb is absent
in 60% of the cases, flail in 30% and normal in 10%. There is a
tendency to autopollicization of the index digit. The MP joints
are usually hyperextensible and may have a significant flexion
block. There are usually flexion deformities of the PIP joints.
Both are probably a result of primary joint deformities and
aberrant muscle insertions. Muscular abnormalities in the radial
club hand deformity can be lumped into a statement that
muscles of origin or insertion on the radial elements of the
forearm are absent or abnormal. This includes the biceps,
brachioradialis, supinators, pronators, flexor pollicis longus,
thumb extensors and abductors. The radial sensory nerve is
usually absent, with the median nerve assuming its innervation.
Usually there is no demonstrable defect in the sensory exam.
The radial artery is inconstantly present.
X-ray findings include a partial to total absence of the
radius. The ulna is relatively straight in complete absence of the
radius (Fig. 3) and usually bowed to some extent in partial
absence of the radius (Fig. 4), probably because of the tethering
of the radial remnant. The carpus is radially deviated. and
volarly subluxed.
The total degree of functional disability is related to
intelligence, prehension capability, elbow flexion and wrist
RADIAL CLUB HAND 165

ry radial deficiency.
FIG. 3. Roentgenographic appearance of an intercala
The thumb and part of the radius are present.

ray defect. The

FIG. 4. Roentgenographic appearance of a complete radial
thumb is absent.
166 W. H. BOWERS

motion. The shoulder range of motion is usually good, with

good girdle musculature. Elbow range of motion may be
abnormal, with a flexion deficit commonly seen in complete
absence of the radius. The wrist is abnormally hypermobile.
Prehension is accomplished in severe cases by marked radial
clinarthrosis, the fingers using the forearm as a thumb post.

Assessment and Consideration for Surgery

Intelligence. The hand is a brain-operated organ and is of

little use to a person with the mental incapacity to perform
simple tasks with his hands.
Correction cannot be obtained without surgical inter-
vention. Permanent correction cannot be obtained without
wrist stabilization. The question, can function be improved?
must be answered. Function as a whole is diminished if grasp is
not increased by surgical measures. Patients with moderately
severe MP joint flexion blockade may not measurably improve
their grasp and grip following wrist procedures designed to
increase the mechanical advantage of the finger flexors. The
degree of MP flexion improvement can be estimated by noting
the difference between active MP flexion and passive MP
flexion. Most procedures diminish the mobility of the wrist
joint to some extent, especially the ability to radially deviate
the wrist. Thus, elbow flexion becomes very important in the
functional evaluation of the upper extremity. This is necessary
for the hand to be brought in proximity to the mouth. A last
note is that a normally functioning and normal-appearing hand
cannot be achieved by surgery. The parent should be aware of
this.
Cosmesis. Cosmetic desires are based on the following
elements:
1. A short forearm.
2. A radially deviated wrist.
3. Absence of a thumb.
The mature length of the ulna in an affected forearm is 50% to
70% of that of normal, depending on the amount of ulnar
bowing present. The forearm appears shorter than this because
of wrist and hand position. Damage to the ulnar epiphysis in
childhood will diminish this potential growth.
RADIAL CLUB HAND 167

Contraindications

Absolute:
1. Mental deficiency.
2. A combination of bilaterality, no thumbs, severe radial
deviation and diminished elbow flexion.
Relative:
1. Isolated elbow flexion block, moderate to severe — not
reconstructable.
2. Isolated MP flexion block, moderate to severe.
3. Cosmetic desires alone voiced by the parents.
4. Failure to achieve understanding about expected results
with the parents.
”
Surgical Procedures

Radial soft tissue release. This includes radial skin Z-plasty

with skin graft if necessary, as well as tendon release, tendon
Z-plasty and fasciotomies.
Centralization of the carpus on the distal ulna. Stabilization
by arthrodesis should be delayed until growth is complete. On
the other hand, there are some evidences that centralization of
the wrist over the distal end of the ulna may actually stimulate
growth of the ulna. Centralization will also increase the
effective length of the forearm (Fig. 5). The procedure is well
described in the literature. Some authors recommend a second
stage including tendon transfers from the volar musculature
around the ulnar aspect of the arm to maintain the surgically
.
obtained correction and to decrease the instance of recurrence
can be effectively
Radial deviation of the carpus and hand thus
growth
corrected. Bracing must continue for most of the early
is rare if the
period (Fig. 6). Recurrence of radial deviation
child’s bracing is
initial procedure is well done and the
supervised.
easily done
Ulnar osteotomy for bowing. This procedure is
zed, bowing will
but unless tendon forces are precisely equali
recur. It is at best a seldom indicated proced ure.
d of Green and
Ulnar lengthening is possible using the metho
of the length of the
Anderson as modified by Dick. Up to 20%
dure remai ns investi-
existent ulna can be gained. This proce
168 W. H. BOWERS

FIG. 6. A postcentralization brace.

RADIAL CLUB HAND 169

FIG. 7. Clinical appearance following an index pollicization in a patient

with radial club hand.

of the two
gative and should only be considered if the length
ts a signifi cant surgical
short arms creates a disability that warran
of the patient ’s life in a
exercise involving a year or more
hospital environment.
plateau of
Arthrodesis of the wrist is recommended at the
the patient ’s life. The choice
growth to maintain correction for
on the functi onal object ives of
of this procedure must again rest
the patient.
liberation of the
Prehension augmentation. This includes
izatio n, pollic izatio n and Pousse-
index digit without pollic
Pollic izatio n of the index ray can
Flotant augmentation.
funct ional ly accep table thumb (Fig.
produce a cosmetically and
floati ng thumb using grafti ng, length-
7). Augmentation of the
results in a functional
ening and tendon transfers most often
and cosmetic flop.
Timing
A Plan for Surgical Sequence and

Age Treatment
y
Birth to 6 weeks Corrective cast, bilateral if necessar
170 W. H. BOWERS

6 weeks to 3 months Alternating long arm casts so child can

discover his hands

3 to 6 months (no Radial soft tissue release if the hand is

previous cast not passively correctible
correction)

1 year Centralized carpus on distal ulna with K-

wire fixation in overcorrection (wire
loops in epiphysis and on ulnar shaft
for growth study)

No later than 3 years Pollicization* and subsequent tendon

transfer

3 to 6 years Ulnar osteotomy and ulnar lengthening

p.r.n.(bilaterality required for latter)

12 to 18 years Wrist stabilization by arthrodesis

Wrist arthrodesis is almost always necessary because active

metacarpophalangeal flexion will be diminished by muscle
action to stabilize the wrist. After wrist arthrodesis, metacarpo-
phalangeal and interphalangeal flexion power may increase.

Summary

Radial club hand is a difficult disorder to deal with

surgically. The main question to be considered in deciding
whether or not surgery is indicated is, can the overall functional
capacity of the patient be improved? Cosmesis is a secondary
objective and should never supplant the primary objective of
function. If contraindications are carefully recalled and the plan
of treatment undertaken, a satisfying result can be obtained.

*Pollicization should be done as follows: In the bilateral cases with no

thumbs on either side but normal fingers, at least the dominant index
should be pollicized. If there is an abnormal digit on the dominant side, it
should be pollicized in preference. In a unilateral case, some state that an
abnormal digit only should be pollicized; however, the author’s preference
is to seek pollicization in these unilateral cases if all has gone well in the
treatment program to this point. Tendon transfers are frequently required
to augment thumb motion.
RADIAL CLUB HAND al

Bibliography
Bora, F.W., Nicholson, J.T. and Cheema, H.M.: Radial meromelia, the
deformity and its treatment. J. Bone Joint Surg. 52A (5):966-979,
1970.
Carroll, R.E. and Louis, D.S.: Anomalies associated with radial dysplasia.
J. Pediatr. 84 (3):409-411, 1974.
Flatt, A.E.: The Care of Congenital Hand Anomalies. St. Louis:C. V.
Mosby Co., 1977.
Heikel, H.V.A.: Aplasia and hypoplasia of the radius. Acta Orthop. Scand.
[Suppl. ]|39:1, 1959.
Lamb, D.W.: The treatment of radial club hand. Hand 4:22-30, 1972.

Self-Evaluation Quiz

1. Cosmesis is a major objective in the treatment of radial club

hand. *
a) True
b) False
2. Signigicant associated anomalies occur with radial club hand
in what percentage?
a) Less than 25%
b) 25% to 50%
c) 50% to 80%
d) 80% to 100%
3. Wrist fusion should always be performed as patients reach
skeletal maturity.
ajeecrue
b) False
with
4. The thumb is absent in what percentage of patients
radial club hand?
a) Less than 10%
b) 30%
c) 60%
d) 100%
no thumbs and
5. Ina patient with bilateral radial club hand,
ction shoul d begin with:
elbow extension deformities, corre
a) Centralization
b) Pollicization
c) Z-plasty
d) Bracing
e) No treatment
eZ, W. H. BOWERS

6. Ulnar lengthening should be routinely considered in bi-

lateral radial club hands.
a) True
b) False
7. Augmentation of a Pousse-Flotant should be performed in
preference to pollicization.
a) True
b) False

Answers on page 527.

 Surgical Management of the
Hypoplastic Hand
Norman J. Cowen, M.D.

Objective

The purpose of this paper is to acquaint the reader with

the various types of hypoplastic hands, with the various
techniques that are available to improve function and with
the’ tremendous potential that young tissue has for develop-
ment if given some help. Emphysis is placed on the
importance of sensibility, on parent receptiveness and on
early surgical intervention when indicated.

one
Reconstruction of the hypoplastic hand continues to be
problem s in hand surgery today. I am
of the most demanding
severe cases such as aplasia of the hand in
referring to the more
bones and soft tissue but practica lly no
which there are wrist
of the fingers is
metacarpals or phalanges (Fig. 1A). Aplasia
palm can be
another example (Fig. 1B and C). Most of the
can be entirely
present with or without a thumb. The fingers
or without nails.
absent or present merely as tiny nubbins with
involving all the
The combination of total complex syndactyly
as the ‘rose bud”
digits and severe hypoplasia is known
coupled with total
deformity (Fig. 1D). A severe central deficit
as a ‘“‘horse’s
complex syndactyly and hypoplasia is known
synostosis and one
hoof” deformity (Fig. 1E). It has a terminal
has little if any
common nail for all the digits. Such a hand
functional capacity.
problems has been
The traditional treatment of these hand
in order to give them an
to fit the children with a prosthesis,
n, Washington, D.C.; President
Norman J. Cowan, M.D., Hand Surgeo
of the National Hand Research and
and Chairman, Board of Directors
tant, National Upper Extremity Rehabili-
Rehabilitation Fund, Inc.; Consul
tation Clinic, Washington, D.C.

173
FIG. 1. Examples of various types of hypoplastic hands. (A) Radiograph
of an aplastic hand. (B) Hand with aplastic fingers. (C) Aplastic hand with
nubbins bearing fingernails. (D) Bilateral ‘‘rose bud’’ deformities. This is a
combination of complex syndactyly and hypoplasia. (E) The “‘horse’s
hoof”’ deformity.
RECONSTRUCTION OF HYPOPLASTIC HAND 175

assisting extremity. In an aggressive program, this can first be

done when the child attains sitting age. He is fitted with a unit
arm. As the child gets older, a terminal device can be added and
later an elbow unit. Unfortunately, as functional as these may
be, they have no sensation; therefore, in the unilateral situation,
the child rarely uses them except when visiting his physician or
his physical therapist. No prosthesis can replace a reconstructed
hand that has good sensation. Therefore, the major considera-
tion in the reconstruction of a hand is to maintain good
sensation. Without it, the patient is better off with a prosthesis
because the prosthesis can look much better than anything that
one can build for the child. Any child whose parents can
emotionally handle multiple operative procedures can be a
candidate for reconstructive surgery. If, however, the parents
cannot handle the stresses of surgery, then the patient is better
treated by prosthetic fitting.
If one elects to go ahead with reconstruction, there are
several stages in the reconstruction of such a hand (Table BY.
Constricting hands must be released to prevent edema or
progressive loss of parts of the digits. Bone grafts can be used to
fill in defects and provide an additional digit or two. Existing
digits can be lengthened. Web spaces can be exaggerated in
depth, adding length to the fingers at the expense of the palm.
This is known as dactylization or phalangization. Pollicization
of a digit to make it into a thumb greatly adds to the functional
capacity of the hand. Ray transfer is used when there are more
metacarpals than fingers on the hand, in order to shift the
fingers over to the ulna side and thereby increase the thumb
es
web space. Tendon transfers, arthrodeses and arthroplasti
complete the list of the surgical procedures.
Because of the threat of vascular compromise, severe
bands require early and vigorous treatment. In
constricting
astic Hand
Table 1. Stages in the Reconstruction of the Hypopl
_ Release constricting bands
_ Bone grafts to fill defects
_ Lengthen existing digits
. Phalangization (dactylization)
_Pollicization and ray transposition

gy _ Tendon
sy
BSS
(ie
fon transfers, arthrodesis, arthroplasties
 ——

176 N. J. COWEN

some cases they may be severe enough to require surgery in the

neonatal period. These can be broken up in either of two ways:
by multiple Z-plasties or by multiple Y-V flap advancements. If
the constricting band extends around only half of the circum-
ference, then the multiple Z-plasty offers a good treatment (Fig.
2). If, however, the constricting band is entirely circumferential
(Fig. 3A), then Z-plasties all the way around might compromise
the venous drainage and the digit may be lost. In this case, it is
better to use three Y-V flap advancements placed at even
intervals around the circumference (Fig. 3B). This procedure
can often be done at the same time as some other major
procedure.
The next stage is to fill in bone defects with bone grafts.
There are two types of defects that can be so treated (Fig. 4).
The first is the intercalary group, in which an extra digit can be
formed by adding longitudinally oriented bone grafts. In the
second group, the phocomelic group, there are more bones
distally than proximally. By placing bone grafts proximally, one
can even up the number of bones in the proximal and distal
rows, which may result in an extra digit or two. The bone graft
comes from the proximal phalanx of the 2nd, 3rd, 4th or 5th
toe of either foot. If a proper incision is made in the skin and if
a subperiosteal dissection is carried out, then no deformity of
the toe will result (Fig. 5).
An example of the phocomelic group is the ‘“‘horse’s hoof”
deformity (Fig. 1E). You might say that this could be divided
into a thumb and one finger to provide pincer grasp (Fig. 6A).
True, but if a third digit could be created, the patient would
have “‘chuck”’ grasp, which is of much greater value. With the
three-digit ‘‘chuck’”’ grasp, the patient has excellent control of
an object, whereas with pincer grasp, this is not the case. Two
bone grafts are placed in the proximal defect (Fig. 6B).
Immediately following surgery the hand looks unchanged
except for the incision. The thumb is first separated by a
phalangization procedure (Fig. 6C). A few months later the
little finger can be separated (Fig. 6D), providing the desired
three digits. In this patient a third division was possible (Fig.
6E), providing a fourth digit as a bonus. After rotation of the
thumb digit (Fig. 6F), the hand will have good functional
capacity and can be used to grasp small and large objects. The
 constricting bands. (B) Same
FIG. 2. (A) Hypoplastic hand with severe
tion of the band to one half of the circumference.
hand showing the limita
constr icting bands by multiple
(C) Same hand after release of the
Z-plasties.
 178

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pueq
Ie PUNO oy} aalyUS sseqJO ey} 21341] ‘Aasulj
(gq) owieg puey
sump “Alosans
ayy, Mode syulod07 ayy asvajer
Jo 904} pueq
Aq suo JO sa14y, A- deijJ syuoeuaouRApe
paoeid
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sey osfe
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N. J. COWEN
RECONSTRUCTION OF HYPOPLASTIC HAND ees)

BONE GRAFTS TO FILL DEFECTS

1. Intercalary group — creates potential for additional

digit

OQ Q40
0OO O\—~ dag
00
oo 0O

7s:
2. Phocomelic group (defect proximally) — adds
stability when divided into separate digits

O00 alt
08 90
FIG. 4. Diagram illustrating types of defects that can be filled in
with bone
grafts.

out
parents have taken home movies of the child carrying
use of both hands togethe r and
various tasks involving the
without
separately. He has normal sensation and uses the hand
is such that it is difficul t to distingu ish
looking at it. His facility
between his reconstructed hand and his normal one.
rd tech-
In dividing the hand into digits, one uses standa
divisio n of syndac tyly. The basic techni que
niques for the
ns to avoid
involves a dorsal and volar triangle and zig-zag incisio
is formed by
flexion contractures (Fig. 7A). The web space
set proximally or
overlapping the two triangles and it can be
p (Fig. 7B). It is
distally, depending on how much they overla
both digits. This
best to accept the need for skin grafting on
is less apt to try to
approach requires less planning and one
which may result in
squeeze opposite skin flaps together,
A second technique,
venous congestion and loss of the digit.
ed V was described by
using a dorsal rectangle and a volar invert
grafts on each side of
McIndoe (Fig. 8A). It still requires skin
ed V has opened up to
the finger (Fig. 8B). Note how the invert
8C).
accept the end of the rectangle (Fig.
180 N. J. COWEN

FIG. 5. Surgical removal of a proximal phalanx from the fourth toe to be

used as a bone graft. Use of a proper skin incision and a subperiosteal
dissection prevents residual deformity of the toe in children.

It should be emphasized that phalangization is not just a

web deepening (Table 2). It is an attempt to recreate the normal
finger to palm ratio of 2:3 which we all have. I always use skin
grafts. I do not feel it makes any difference to the hand whether
one uses split-thickness or full-thickness skin grafts. I now tend
to use mostly full-thickness grafts from the groin because the
donor site can be hidden in the skin crease. Usually it is
necessary to split back the division of the common digital nerve
into proper digital nerves by cutting the epineurium. A digital
artery is usually tied off. The intrinsic muscles are mobilized so
that the cleft between the digits can be deepened. This usually
requires division of the intervolar plate ligament and any other
RECONSTRUCTION OF HYPOPLASTIC HAND 181

transverse structures proximal to the level of the desired web

space. In the thumb web space I usually begin with some form
of Z-plasty, adding other forms of flap transposition and skin
grafting as the intended web deepens. It is often necessary to
detach the origin of the first dorsal interosseous muscle from
the first metacarpal bone and to recess the attachment of the
transverse head of the adductor pollicis muscle.
An example of a 6-year-old child with combined hypoplasia
and complex syndactyly is seen in Figure 9A. The more distal
dotted line (Fig. 9B) shows the level that is intended for the end
of the palm. The web spaces are exaggerated in depth in order
to allow for some distal migration as the child grows (Fig. 9B).
Note that an attempt is made to have the thumb project from
the proximal half of the palm, which is the normal position
(Fig. 9C and D). Using these phalangization techniques, a hand
that looked quite deformed (Fig. 9A) can be changed into a
hand that looks and functions very well (Fig. 9E).
Now we come to the lengthening of existing hypoplastic
digits. This can be accomplished by two techniques. The staged
bone grafting of the proximal phalanges of the toes has been
used extensively by Dr. Robert E. Carroll of New York
(personal communication). More recently, I [1] have been using
in
the distraction technique described by Matev [2] of Bulgaria
Isadore Kessler from Tel Aviv [3]. I call
conjunction with Dr.
ty
this last technique the distraction augmentation manoplas
a two-stage procedur e. Reconstr uction of a
(DAM) and it is
multiple bone
hand with aplastic fingers will demonstrate the
(Fig. 10A-D). The x-ray film shows that
grafting of Carroll
major bones that are missing. A bone graft
metacarpals are the
will show it
from one of the toes is put into place. An x-ray
n is repeated
being held with a K wire (Fig. 10C). The operatio
one ends up with a fair amount of bone in
and, eventually,
appear to have been
place. Clinically, the nubbins do not
been moved distally
lengthened since the web spaces have also
which is much
(Fig. 10E). However, a palm has been made
with phalangization
longer. This hand will now be divided
and G). Note in Figure
procedures into various digits (Fig. 10F
not a thumb but an
10G that the thumb in this hand is really
it should be positioned in
extra digit. In order to be a thumb,
the little finger so that
front of the index finger and face
182 N. J. COWEN

FIG. 6. (A) Radiograph of the “‘horse’s hoof” deformity seen in Figure 1E.
(B) Radiograph of the same hand after two bone grafts have been placed
centrally in a longitudinal orientation. (C) Same hand after separation of a
thumb. (D) After separation of a little finger. (E) After a third division
providing a fourth digit. (F) After pseudopollicization of the thumb, with
almost full opposition in grasping a pencil cover.
RECONSTRUCTION OF HYPOPLASTIC HAND
184 N. J. COWEN

FIG. 7. (A) Diagram of a basic technique for division of syndactyly using

basal triangles and zig-zag incisions. (B) At surgery overlap of the triangles
forms the base of the web. Flaps formed by the anterior and posterior
incisions often can be approximated at their tips, leaving diamond-shaped
defects along the fingers which require skin grafting.
 a
=“, Ho1Q
1a 3
XW \¢
i

ry} {
seomaeroeineomtis , Te
bry]
if i i 3
+ bP ay
titi

tie

FIG. 8. (A) Diagram of a second tech-

nique described by Mclndoe, using a
dorsal rectangle and a volar inverted V.
(B) Diagram showing the technique above
after advancing the rectangle, as viewed
from the dorsum. (C) Clinical view of the
same technique from the volar side. The
inverted V has opened up to receive the
distal end of the rectangle.
186 N. J. COWEN

Table 2. Phalangization (Dactylization) of the Hand

. Not just web deepening — recreate the normal finger: plam ratio of 2:3
. Standard techniques for division of syndactyly

. Always use skin grafts

. Split back nerves by dividing their epineural sheath

. Tie off one digital artery

. Develop a cleft between the intrinsic muscles to the involved digits

Sey.
—
Ess
$y
1S
wen) Divide the intervolar plate ligaments and any other transverse structures proximal
to the level of the desired web space
8. In the thumb web space, be prepared to release the origin of the first dorsal inter-
osseous muscle from the first metacarpal and to recess the attachment of the
adductor pollicis muscle

opposition is possible. In order to do this, a formal pollicization

of this digit can be carried out or a pseudopollicization can be
done. The latter is an abduction-rotation osteotomy with a skin
graft to widen the web space. This was performed in this child’s
hand and one can see that the thumb looks much more like a
real thumb (Fig. 10H). It can now be used to oppose the other
digits (Fig. 101) and to grasp objects (Fig. 10J).
In 1970, Matev published a technique for lengthening the
metacarpal in adults who have had their thumb amputated [2].
His cases were similar to the following patient. A 22-year-old
male lost his thumb proximal to the MP joint in a high-voltage
injury (Fig. 11A). He played the violin and did not want
pollicization of one of his four fingers, all of which he needed
to use on the strings. The technique that Matev described
involves an osteotomy site and a distraction device connecting
them (Fig. 11B). The little screws at the bottom can be turned,
and with one entire rotation, the distraction device separates
the osteotomy site by 1 mm. This can be turned by the patient
himself in increments of part of a turn several times a day.
Depending on the number of days that the patient wears this
device, a good deal of length can be obtained (Fig. 11C). In this
patient, the metacarpal was lengthened so much that it was
almost the same length as his normal thumb (Fig. 11D). He
continues to play the violin (Fig. 11E) and also plays basketball
for Wesleyan College, which attests to the function of the hand.
FIG. 9. (A) Hand of a 6-year-old boy
with complex syndactyly and hypoplasia.
(B) Intended skin incisions for dactyliza-
tion of 1-2 and 3-4. A double Z-plasty on
the skin is being used in the thumb web
space. The dotted line distally shows the
intended level of the new web spaces. The
proximal dotted line shows the level of
intended thumb origin. (C) Volar and (D)
dorsal views of the hand during pro-
cedure. (KE) Same hand after two dactyli-
zation procedures and arthrodeses of the
DIP joints.
188 N. J. COWEN

FIG. 10. (A) Photograph and (B) radiograph of the hand seen in Figure
1C. There is a substantial loss of metacarpal bone. (C) Radiograph and (D)
photograph demonstrating placement of a bone graft from the proximal
phalanx of a toe into the palm (Carroll bone grafting). (E) After several
Carroll procedures. (F) After the first and (G) second phalangization
procedures. (H) After a “pseudopollicization” of the thumb. (1) Opposi-
tion of the thumb and (J) function of the hand holding an object.
RECONSTRUCTION OF HYPOPLASTIC HAND 189
FIG. 11. (A) The playing hand ofa
22-year-old, right-handed male vio-
linist following amputation caused
by a high-voltage injury. The pa-
tient refused pollicization of any of
his fingers, all four being needed on
the strings. (B) After osteotomy of
the remaining thumb metacarpal
and attachment of the Matev dis-
traction device. (C) After DAM
stage II. Lengthening of 6.8 cm was
obtained. (D) Comparison .of the
patient’s lengthened thumb to his
normal right thumb. (E) The hand
while playing the violin. (A, C and
D are reprinted courtesy of Ortho-
paedic Review, Vol. VII, No. 6,
June 1978, p. 47.)
RECONSTRUCTION OF HYPOPLASTIC HAND 191

Although Matev did not apply this device to the hypoplastic

hand, Kessler and I have been using this on young children (Fig.
12A) and on adolescents (see Fig. 19A). Additionally, I have
started using this in a series of very young children (see Fig.
15A) and in infants with tiny little hands (see Fig. 17A). The
technique is as follows. The metacarpals are osteotomized and
the device is applied (Fig. 12B and C). Distraction begins at the
rate of 1 mm a day, which is the rate of nerve regeneration.
X-rays are taken at various intervals to monitor the progress
(Fig. 12C-E). When sufficient length has been obtained, a
second operative procedure is done which is a bone grafting
procedure (Fig. 12F). Originally, the bone graft was taken from
the proximal ulna. Follow-up x-rays demonstrate that the cavity
at the donor site fills in readily (Fig. 13A). Lately, so much
length has been obtained, and so many digits have been
lengthened at the same time that the proximal ulna has become
an insufficient source of bone and the fibula is now being used
routinely. A sequence of x-rays of the fibula following surgery
will show that in a child the fibula is regenerated in about 1% to
2 years if a subperiosteal dissection is performed and the
periosteal cuff closed before the skin suture (Fig. 13B and C).
I am now using several devices at the same time to lengthen
different parts of the hand (Fig. 14A); after lengthening,
phalangization procedures are usually required (Fig. 14B). I
now refer to this surgery as the distraction augmentation
manoplasty stages I, II or III (or in short as DAM I, DAM II or
DAM III). It is even possible to lengthen the hand and an
individual digit at the same time (see Fig. 19C).
Some clinical examples should show the potential of the
DAM technique.
P.M. was a 14-month-old child with a severely hypoplastic
hand (Fig. 15A). X-rays and clinical evaluation revealed very
little bone in the hand and thus a Carroll bone grafting
procedure was performed initially (Fig. 15B). The presence of
some bone is a necessary condition for the DAM technique (Fig.
15C). The distraction device was applied when the child was 24
months of age (Fig. 15D) and was worn for nine weeks (Fig.
15E). The lengthening had been so extensive that one of the K
wires almost pulled loose distally. Three months after DAM II
the bone grafts were healed and the hand supple (Fig. 15F).
Lengthening of 2.3 cm was obtained and the palm was now
FIG. 12. (A) Hand during DAM stage I. Application of device, osteotomy
of bones and initial distraction. (B) Radiograph of hypoplastic hand prior
to DAM stage I. (C) Radiograph showing amount of distraction after three
days. (D) Radiograph after 17 days. (E) Radiograph after 64 days. (F)
Radiograph two months after DAM stage II, showing incorporation of
bone grafts from the fibula. Three fingers and a thumb are anticipated
following phalangization. (Reprinted courtesy of Orthopaedic Review,
Vol. VII, No. 6, June 1978, p. 46.)
 FIG. 13. (A) Radiograph ofa
proximal ulna bone-graft do-
nor site immediately after
surgery (bottom) and 1%
years later (top). The bone
has almost completely re-
generated. (B) Radiograph of
a fibula bone-graft donor site
immediately following sur-
gery (right) and nine months
later (left). (C) Radiograph of
the same fibula 15 months
after surgery (left) and two
years after surgery (right).
The bone regenerates as in
the proximal ulna. A_ sub-
periosteal dissection is done.
 N. J. COWEN
194

===
=
== :
é

neonatal
FIG. 14. (A) Hand that was amputated and skin grafted in the
being
period because of vascular occlusion. The thumb and hand are
d simultane ously but separately . (B) Same hand following
lengthene
the hand
lengthening and phalangization; 5.0 cm of length was obtained in
3.5 cm in the thumb. (A is reprinted by countesy of Orthopae dic
and
Review, Vol. VII, No. 6, June 1978, p. 48.)

much longer than the thumb. The first phalangization pro-

cedure was then performed (Fig. 16A).
Eventually, this palm was to be divided into two or three
digits. Prior to further division the parents requested that more
length be obtained and the child underwent a second staged
distraction. X-rays were taken on the 24th, 50th and 85th days
of distraction and after the bone grafting procedure on the
 Pespet
paeeen
gale
HENEE
ay
HFone
beeen
e

a
aoe
<ee.

FIG. 15. (A) Hypoplastic hand of a 14-month-old infant. (B) Same hand
after a Carroll bone grafting procedure. When no bone is present a Carroll
procedure is a necessary preliminary to the DAM technique. (C)
Radiograph of the same hand shortly after birth (left) and following the
of the
Carroll bone grafting procedure (right). (D) After application
of age. (E) Hand just prior to DAM stage
distraction device at 24 months
stage Il.
II, nine weeks after DAM stage I. (F) Three months after DAM
have been
Note that the hand has been stretched out and that the nubbins
of the thumb.
“left behind.’? Compare with Figure A for relative position
of Orthopaedic
Lengthening of 2.3 cm was obtained. (Reprinted couresty
Review, Vol. VII, No. 6, June 1978, p. Bile)
 —

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119th day (Fig. 16B-E) 7.6 cm of length was obtained, but this
was shortened to 7.1 cm in order to gain some extra width
which would allow the placement of three longitudinal struts of
bone, each 9.5 cm in length. This should allow the future
division of the palm into three separate fingers. Figure 16F
demonstrates a comparison of length of the distracted left hand
to that of the normal right hand just prior to DAM II.
D.Z. was a 9-month-old infant with syndactyly and hypo-
plasia of the middle, ring and little fingers; indeed, the index
finger was also quite small (Fig. 17A). Bone was put into the
fingers (Fig. 17B). The distraction device was applied and one
can see that from microdactyly the fingers have advanced to
macrodactyly (Fig. 17C and D). An x-ray was taken three weeks
after bone grafting to check on healing (Fig. 17E). Three
months after DAM II the patient was ready for the dactyliza-
tion procedures (Fig. 17F and G). After the second dactyliza-
tion procedure, the hand had a much better appearance and
excellent functional capacity (Fig. 17H).
M.A. was a 2-year-old girl who was born with only wrist
bones and an ulna and radial nubbin on her right hand (Fig.
18A). After several Carroll bone grafting procedures and an
opponensplasty, inadequate length still hampered the use of the
hand (Fig. 18B). One of the earlier distraction devices was
applied and worn for three weeks (Fig. 18C). After lengthening
and dactylization procedures the hand had a thumb and two
fingers (Fig. 18D and E). This child has subsequently won every
beauty contest she has entered and does a twirling routine as
her ‘‘talent.”’
G.C. as a 15-year-old boy was somewhat withdrawn and
would try to conceal his right hand (Fig. 19A) in his pocket. His
x-ray showed complete absence of the index, long and ring
fingers and only a proximal phalanx on the thumb and little
finger (Fig. 19B). He underwent lengthening of the third and
fourth metacarpals and the proximal phalanx of the little finger
(Fig. 19C and D). On the 76th day there was 51 mm of
distraction of the metacarpals and 32 mm of the little finger
(Fig. 19E and F). Clinically one can see that distraction
proceeded so far that the nubbins were left behind. The index
metacarpal was used as a bone graft to the little finger. Two
large pieces of fibula were grafted to the metacarpals (Figure
 There is a
FIG. 17. (A) Hypoplastic right hand of a 9-month infant.
fingers and a construct ion band on the
syndactyly of the middle and ring
(B) During a Carroll bone lengtheni ng. (C) At DAM stage I. (D) Just
latter.
prior to DAM stage II. The microdactyly has been convered to
tyly. (E) Radiogra ph three weeks following DAM stage II. The
macrodac
ulna. (F) Three months after DAM stage
bone graft was from the proximal
During phalangi zation of 2-3 and 4-5, three months after DAM
II. (G)
phalangization operation.
stage II. (H) Two weeks after the second
ed courtesy of Orthopae dic Review, Vol. VII, No. 6, June 1978,
(Reprint
p. 50.)
200 N. J. COWEN
201

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e pue eisejdodAy adtaaes yyIM [Is plo-aeah-Z eB JO spuey (V¥) ‘ST “OIA
OF HYPOPLASTIC HAND
RECONSTRUCTION
 - A

FIG. 19. (A) Hand of a 15-year-old boy. (B) Radiograph of the same hand.
(C) Photograph and (D) radiograph of the hand after DAM I. The third
and fourth metacarpals and the proximal phalanx of the little finger are
being simultaneously lengthened using two distraction devices. The second
metacarpal is planned as the future bone graft for the little finger. (E)
Photograph and (F) radiograph on the 76th day of distraction. The
metacarpals have been lengthened 5.1 cm and the little finger 3.2 cm. The
nubbins were “left behind.’ (G) After DAM stage II. (H) After
phalangization of 1-2 and 4-5. (I) After phalangiza tion of 3-4 and revision
of the nubbins. (J,K) Views demonstrating pinch to the little finger.
204 N. J. COWEN

19G). The first phalangization was between 1-2 and 4-5 (Fig.
19H). Note the excursion of the thumb. During the second
phalangization the nubbins were recessed into the digits with
Y-V flap advancements, giving the hand a good cosmetic
appearance (Fig. 191). The patient had good motion in both his
thumb and little finger (Fig. 19J and K). This teenager now
works part-time as a waiter in a restaurant and has no qualms
about shaking hands.
The augmentation distraction manoplasty appears to be a
great asset in obtaining sufficient length for grasp and is proving
quite reliable.
In summary, the skin, tendons and vessels have unbelievable
potential for growth, but these structures must be stressed to
obtain this potential. It is best to do it early. Finally, we must
turn away from the easy “‘out”’ of saying, ““Let’s see him again
next year and reevaluate the situation.” Rather, we should act
now, for nature will respond if we prod her.

References

1. Cowen, N.J. and Loftus, J.M.: Distraction augmentation manoplasty.

Technique for lengthening digits or entire hands. Orthop. Rev. 7
(6):45-53, 1978.
2. Matev, I.B.: Thumb reconstruction after amputation at the metacarpo-
phalangeal joint by bone lengthening. J. Bone Joint Surg. 52A:957-
965, 1970.
3. Kessler, I., Baruch, A. and Hecht, O.: Experience with distraction
lengthening of distal rays in congenital anomalies. J. Hand Surg. 2
(5):394-401, 1977.

Self-Evaluation Quiz

1. The treatment of complex syndactyly should be delayed

because distal migration of newly created web spaces will
require additional web space surgery later.
a) True
b) False
2. Constricting bands which are circumferential should be
released by Z-plasties in one operation to avoid progressive
loss of the digits involved.
a) True
b) False
RECONSTRUCTION OF HYPOPLASTIC HAND 205

3. Reconstruction of the hypoplastic hand requires at least a

few functioning metacarpophalangeal joints.
a) True
b) False
4. In syndactyly surgery, arranging the skin defects so that
skin grafting is needed on both digits decreases the
propensity to directly suture together opposite skin flaps on
one digit, and thereby decreases the incidence of venous
congestion with possible loss of a digit.
Ayre
b) False
5. In the unilateral situation, cosmetic prosthetic hands are
readily accepted by the patient even though sensibility is
lacking.
ay True
b) False
6. For a thumb to function as such and not just as a fifth digit,
it must be positioned in front of the index finger so that it
can oppose each finger.
a) ei rue
b) False
of web
7. Phalanglization or dactylization is an expansion
part of the palm is convert ed into
space surgery in which
the normal 2:3 ratio finger to palm
digits in order to restore
length.
ay. irue
b) False
as a bone graft in
8. Use of the middle two thirds of the fibula
iostea lly, is discouraged
children, even if taken subper
because of resulting weakness to the ankle.
ay) .rue
b) False

Answers on page 527.

 Polydactyly —
A Ten-Year Experience
at Duke Medical Center
Mitchel A. Lipton, M.D. and J. Leonard Goldner, M.D.

Objective
Polydactyly is the most common congenital anomaly of
“the upper extremity. Ten years’ experience at Duke Medical
Center is reviewed, with emphasis on the incidence, site of
polydactyly, racial differences, operative plans and the
importance of observation until adulthood.

Introduction

Patients with extra digitis examined and treated at Duke

University Medical Center during the past ten years have been
reviewed. Polydactyly means many digits and in this instance
many refers to more than five on each hand. Other descriptive
terms referring to this condition are accessory digits, super-
numerary digits, extra digits and bifid fingers [1]. This deform-
ity is usually considered to be the most common congenital
anomaly of the upper extremity [1-3]. References to polydac-
tylism date back to the Bible, when the giant of Goth “‘had on
every hand six fingers and on every foot six toes’ [4]. The
transmission of the genetic trait is autosomal dominant with
variable expression [5]. Geographic areas of endemic polydac-
tylism have been recorded where the rule is more than ten
fingers, rather than the exception. In 1898, Boinet described
the family of Foldi as an isolated Arab tribe at the southern tip
er
ae a ee ee
J.
Mitchel A. Lipton, M.D., Private Practice, Phoenix, Ariz.; and
Division
Leonard Goldner, M.D., James B. Duke Professor and Chairman,
N.C.
of Orthopaedic Surgery, Duke University Medical Center, Durham,

207
208 M. A. LIPTON AND J. L. GOLDNER

of the Arabian peninsula, whose members all had six

fingers [6]. De Linares, in 1930, described a town near Madrid,
Cervera de Buitrago, where over two thirds of the inhabitants
had a supernumerary thumb [7]. In 1938, Bates described an
Australian aboriginal tribe whose members had six fingers and
six toes [8].

Duke Medical Center Experience:

1969 Through 1978

Medical records of patients with polydactyly were reviewed

at Duke Medical Center for the ten-year period from 1969
through 1978 (Table 1).
A total of 171 patients was noted to have polydactylism. Of
these, 58 patients had left-hand involvement, 29 persons had
extra digits on the right hand and 84 had both hands affected.
There was a total of 255 digits considered to be abnormal.
Ninety-four of this group were males and 77 were females. The
extra digit arose from the ulnar border of the hand in 149
patients and 22 had duplication of the thumb. This distribution
gave a ratio of 7:1, which is similar to the 8:1 distribution
described by Carroll [9]. This group differed significantly from
those described by Flatt, who recorded 113 thumb and 110
little finger duplications [3]. This difference may be due in part
to the larger black population in North Carolina as compared
with the lesser black population in Iowa during the time that
these statistics were occurring. The available evidence suggests
that there is a significant racial predilection related to the site of

Table 1. Incidence of Polydactyly at Duke Medical Center

1969 to 1978
Live births:
Total 17,638
Black 13,784
Caucasian 3,734
Other (Indian and Oriental) 120

Blacks with polydactyly:

137 Incidence 1 per 100

Caucasians with polydactyly:

34 Only 15 born at Duke, 1 per 250
POLYDACTYLY 209

involvement of the polydactyly. The Duke group of 22 patients

with duplicated thumbs showed 20 to be Caucasian and 2 were
black, a ratio of 10:1. However, of the 149 patients with an
extra digit on the ulnar border, 135 were black while only 14
were Caucasian. The same ratio of 10:1 was present, but
reversed.

Birth Statistics

At Duke Medical Center during the years 1969 to 1978

there were 17,638 live births (Table 2). Of the total live births,
13,784 were black, 3,734 were Caucasian and 121 were Indian
and Oriental. Since there were 137 blacks with polydactyly, the
incidence is 1 per 100. During this same time 15 of the total 34
Caucasians examined were born at Duke with polydactyly and
this represented an incidence of 1 per 250.

Associated Abnormalities
Of the 171 patients seen at Duke from 1969 to 1978, 26
had other congenital anomalies. Usually these anomalies were

Table 2. Distribution of Polydactyly at Duke Medical Center

1969 to 1978
Total patients: 172

Total digits: 255

Hand Involvement

Bilateral Left Right

84 58 29

Sex Distribution
Male Female
94 da.

Location on Hand
Radial Ulnar
22 149

Location on Hand by Race

Radial side Ulnar side
Caucasian 20 Caucasian 14
Black 2 Black iL)
210 M. A. LIPTON AND J. L. GOLDNER

syndactylism of the digits and abnormalities of the toes. Facial

and heart defects were also noted (Table 3).

Treatment of Patients with Polydactylism at Duke

Ulnar Border Digits (Postaxial

Duplication)
The extra ulnar border digit is usually attached by a small
skin tag. Ligation of the skin in the newborn nursery has usually
eliminated the part. Occasionally, the digit is moderately large
with a thicker stalk and requires an operative procedure. We
have advised the parents to have the digit removed as quickly as
possible since the ulnar supernumeray digit is never normal,
does not aid hand function and is cosmetically unacceptable.

Central Duplication
Central polydactyly involves the index, long and ring fingers
and was not observed in this group. In several instances,
however, duplication of the central digits was classified as part
of a complex syndactylism rather than polydactyly. The
detailed discussion of central duplication is presented in an
article by Virchel Wood [10].

Radial Duplication (Preaxial

Duplication)
This condition may vary in degree from a broadened nail
bed to a completely formed extra thumb. The extra thumb
should be removed when the child is a few months old. The

Table 3. Polydactyly-Associated Anomalies in 171 Patients

Associated Anomalies No.

Toes 12
Syndactyly 5
Facial abnormalities 3
Congenital heart 3
Hiatal hernia 2
Microcephaly 1

Total 26
POLYDACTYLY 214

dominant thumb is determined by palpation, x-ray and observa-

tion of the first ray as the hand is used. The digit on the ulnar
side of the double thumb is usually larger and better formed,
and the radial digit is the one that is usually excised.
In 1890, Bilhaut described an operative procedure in which
the adjacent sides of both digits were removed and the
remaining radial and ulnar segments were jointed together to
form the single thumb [11]. This procedure may necessitate
splitting the epiphyseal plate, which may result in a central
growth disturbance and a distorted phalanx. Also, the germinal
layer of both fingernails is incised and must be matched
meticulously in order to provide a nail without a split up the
center. The double thumb usually has a flair of the distal end of
the proximal phalanx as part of its deformity, and this segment
is removed easier if one entire thumb is removed rather than
attempting to split each thumb. We have not performed the
Bilhaut ‘‘central wedge resection”? at Duke on any of the
patients with widened or double thumbs, since one thumb was
always better formed than the other and the lesser thumb was
amputated.
Anomalous tendons and attachments are usually associated
with a duplicated thumb [12]. The ulnar thumb may be more
prominent but have an incomplete or hypoplastic or displaced
extensor mechanism. While the accessory thumb is being
removed, the tendons are isolated from this digit and used to
construct a collateral ligament or to reinforce the extensor
pollicis longus or extensor pollicis brevis.
Collateral ligament reconstruction is essential. Unless the
collateral ligaments are anchored to bone they will stretch and
result in an unstable metacarpophalangeal joint. This deficiency
has been the most common one after amputation. If soft tissue
reconstruction has failed and the child is older, arthrodesis has
been selected in certain instances to maintain stability. This has
been possible without shortening of the thumb.
Intrinsic muscles are transferred from the amputated digit
to the remaining thumb in order to augment intrinsic muscle
function and supplement intrinsic muscles that may be hypo-
plastic or absent. Thus, the amputation does eliminate the extra
fingernail complex but does save tendons and, if necessary,
bone. Osseous reconstruction has been done in order to
lengthen the first metacarpal by inserting a small bone graft, by
ile, M. A. LIPTON AND J. L. GOLDNER

correcting an angular deformity of the metacarpal or phalanx

by wedge osteotomy, or by resecting an accessory articular
surface. Since the epiphyseal plate of the first metacarpal is
located at the proximal end of the metacarpal, a segment of the
first metacarpal head can be resected without interfering with
metacarpal growth.
Deletion of the accessory thumb is explained to the parents
as a necessary procedure but one that will not result in a normal
thumb. The remaining digit will be slightly shorter and probably
not as wide as a normal thumb, and limitation of motion
usually occurs at the interphalangeal and metacarpophalangeal
joints. Instability at the metacarpophalangeal joint usually does
not occur if the collateral ligaments are reconstructed, but the
tighter the collateral ligament is made, the less motion at that
joint will result. Intrinsic muscle deficiency or weakness
frequently exists and should be expected. Reinforcement by
external or internal tendon transfers is possible but usually not
necessary. A narrowed thumb-index web space may be pert of
the primary hand deformity. If this is present, then a Z-plasty
or free skin graft to the thumb web may be indicated.
An angular deformity may develop as the child grows older,
because of epiphyseal involvement. Thus, these children should
be observed until they reach full epiphyseal growth.

Summary

Polydactyly is the most common congenital anomaly of the

upper extremity. Ulnar polydactyly was seven times more
frequent than radial at Duke Medical Center during the past ten
years. A racial difference in the site of polydactyly has been
observed.
Treatment of the duplicated thumb requires careful joint
stabilization, tendon reconstruction, metacarpal head trimming
and maintenance of a germinal layer of the remaining nail. A
functional thumb results, but a normal-appearing thumb is
unlikely. The patient should be observed until epiphyseal
closure.

References

1. Kelikian, H.: Congenital Deformities of the Hand and Forearm.

Philadelphia:W. B. Saunders Co., 1974, pp. 408-456.
POLYDACTYLY 213

2. Flatt, A.E.: The Care of Congenital Hand Anomalies. St. Louis:C. V.

Mosby Co., 1977, pp. 228-248.
3. Flatt, A.E.: Problems in polydactyly. In Cramer, L.M. and Chase,
R.A. (eds.): Symposium on the Hand. St. Louis:C. V. Mosby Co.,
1971, vol. 3, pp. 150-167.
. The Holy Bible, King James Version, II Samuel 1:20.
. Barsky, A.J.: Congenital Anomalies of the Hand and Their Surgical
Treatment. Springfield: Charles C Thomas, 1958, pp. 48-64.
. Boinet, E.: Polydactylie et Atavisore. Rev. Med. (Paris) 18:316-328,
1898.
. De Linares, L.G.: Collective polydactylism in a small town. JAMA
94:2080-2081, 1930.
. Bates, D.: The Passing of the Aborigines. London:J. Murray, 1938,
pp. 121-122.
. Carroll, R., cited by Flatt, A.E.: Congenital anomalies of the hand.
Paper presented at the American Academy of Orthopaedic Surgeons
Instructional Course Lectures, Chicago, Illinois, 1970.
. Wood, V.E.: Treatment of central polydactyly. Clin. Orthop.
74:196-205, 1971.
ab. Bilhaut: Guérison d’un pouce bifide par un nouveau procédé
opératoire. Congrés Francois de Chirurgie (4 Session 1889)
4:576-580, 1890.
de Marks, T.W. and Bayne, L.G.: Polydactyly of the thumb: Abnormal
anatomy and treatment. J. Hand Surg. 3 (2):107-116, 1978.

Self-Evaluation Quiz

Polydactyly means many digits. Other descriptive terms

include:
a) Accessory digits
b) Supernumerary digits
c) Extra digits
d) Bifid fingers
e) All of the above
From the study at Duke, which is more common?
a) Ulnar duplication
b) Radial duplication
c) Neither
From the study at Duke, radial duplication was more
common in:
a) Caucasians
b) Blacks
c) Neither
From the study at Duke, the incidence of polydactyly in
blacks is:
214 M. A. LIPTON AND J. L. GOLDNER

a) 1:10
b) 1:100
c) 1:1000
d) Unknown
5. Which factor is true in determining the more dominant
extra thumb:
a) Usually is ulnar
b) Usually is larger
c) Used more in grasp and pinch
d) All of the above
6. Which type of duplication can usually be ligated in the
newborn nursery:
a)Radial
b)Central
c)Ulnar
d)All of the above
e) None of the above
7. The most common congenital anomaly of the upper
extremity is:
a) Radial club hand
b) Syndactyly
c) Polydactyly
d) Absent thumb
8. Polydactyly is transmitted most commonly by:
a) Autosomal dominant with variable expression
b) Sex-linked dominant
c) Sex-linked recessive
d) Spontaneous mutation
9. Common associations with polydactyly include:
a) Epilepsy
b) Liver disease
c) Toe anomalies
d) Hirsutism
10. The Bilhaut procedure involves:
a) Central wedge resection
b) Ligation
c) Amputation
d) MP fusion

Answers on page 527.

Common Office Problems
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 Carpal Tunnel Syndrome
Macy G. Hall, Jr., M.D.

Objective
Carpal tunnel syndrome remains a problematic entity in
management. The anatomical anomalies and variants of the
median nerve are more common than standard textbooks
would suggest. This paper attempts to strengthen the
argument that complications from carpal tunnel release
appear to be due to technical error and often can be
prevented by careful patient selection, knowledge of
anatomy, technique and proper postoperative care.

The carpal tunnel syndrome, or median thenar neuritis, is a

well-known entity and has been documented extensively by
Brain and Wright [1] and Phalen [2]. According to Phalen,
carpal tunnel syndrome was the effect of any condition
producing irritation or compression of the median nerve within
the carpal tunnel by direct damage or secondary compression,
or an increased volume of the contents of the carpal tunnel with
concomitant pressure on the median nerve beneath the trans-
verse carpal ligament (TCL), i.e. an entrapment phenomenon.
The causes and associated diseases of carpal tunnel syn-
drome are numerous, being idiopathic or secondary to acute,
local or distant trauma; rheumatoid, gouty arthritis and
tenosynovitis; diabetes mellitus; Raynaud disease; myxedema;
pregnancy; obesity; soft tissue tumors, including the aberrant
lumbrical insertions; and anomalies of the flexor sublimis.
The pathophysiology of carpal tunnel syndrome (CTS) is
controversial; however, it has been related to direct or indirect
nerve
pressure within the carpal tunnel leading to loss of
ant percent age of
conduction, which is relieved in a signific
Reconstructive
Macy G. Hall, Jr., M.D., Chief, Division of Plastic and
Surgery, Howard University, Washington, D.C.

PANG
218 M. G. HALL, JR.

patients following division of the transverse carpal ligament. Or

is it the result of median nerve (MN) ischemia leading to
internal fibrosis, axon constriction and loss of myelin sheath, or
maybe a combination of the two factors?

Signs and Symptoms

Sir James Paget [3] first described the symptoms of CT

compression in 1854, but it was nearly a century later, in 1930,
that the first successful surgical decompression was credited to
Sir James Learmonth, who believed that the median neuritis
was due to compressive proliferative tenosynovitis.
We are aware of the objective or subjective median nerve
hypoesthesia, the positive Tinel sign (tingling sensation) and
positive wrist-flexion test of numbness and paresthesia within
380 to 60 seconds, as advocated by Phalen in 1951 — which,
incidentally, may not be positive if there is advanced hypo-
esthesia [2]. We easily recognize the middle-aged, obese female
with nocturnal hand cramps, or the construction worker with
bilateral weakened grip. But we must not jump to the freshman
conclusion, however; for it may be a cervical or carpal bone
arthropathy or other compression syndrome. Are the ancillary
studies of electromyography and nerve conduction as valid as
they once were thought to be? Do we take time to classify the
motor function from normal to total paralysis, or the sensory
function from normal to total anesthesia? What is ‘‘normal
motor and sensory latency at the wrist’’? What is initially
affected? These are the questions we must address.

Surgical Anatomy

Surgery of the hand is the most elegant example of pure

applied anatomy. Most surgeons can retain, as a rule, a limited
amount of anatomy — that which is pertinent to their daily
activities. Changes in the scope of surgery necessitate an update
of knowledge pertaining to relevant anatomy in order to avoid
surgical misadventures.
The carpal tunnel is formed by the TCL, which arises on the
ulnar aspect of the hand from the hook of the hamate and
pisiform bone. On the radial side, it is inserted into the
trapezium crest, scaphoid tubercle and sometimes into the
CARPAL TUNNEL SYNDROME 219

styloid process of the radius. The floor is formed by those

glistening structures responsible for IP and DIP flexion.

Variations of the Median Nerve

Within the Carpal Tunnel

In discussing the anatomy, we must be aware of the

variations of the median nerve within the carpal tunnel.
Entin [4] demonstrated that the thenar branch may leave the
median nerve at its ulnar aspect, thereby endangering it during
TCL division. Ulrich Lanz [5] classified the variations of the
median nerve into four groups:
1. Variation in the course of the thenar branch.
2. Accessory branches at the distal portion of the carpal
- tunnel.
3. High division of the median nerve.
4. Accessory branches proximal to the carpal canal.
The following are examples of these groups:
1. Subligamentous thenar branch of MN.
2. Transligamentous thenar branch.
3. Subligamentous thenar branch at its ulnar aspect (after
Entin).
4. Thenar branch on top of TCL.
5. Double thenar motor branch.
6. High division of MN with median artery.
7. High division of MN with thick ulnar part.
8. High division of MN with accessory lumbrical.
9. Accessory branch proximal to the carpal tunnel.
10. Transligamentous proximal accessory branch.
11. Accessory branch from proximal ulnar aspect.
12. Proximal accessory branch running into thenar muscle.

Operative Techniques

Most articles written on carpal tunnel syndrome now

advocate operative treatment for relief of symptoms if conserva-
tive therapy fails, i.e. analgesics, steroids and/or resting splints,
or a change in occupation.
Phalen once stated that the type of incision used is of little
importance, provided the incision does not cross the distal
220 M. G. HALL, JR.

flexion crease at a right angle. On the contrary, a transverse

incision heals with minimal scar but does not allow adequate
exposure, making distal dissection of the TCL inadequate as
well as leading to other complications to be discussed.
There is no surgical controversy as to the value of median
nerve decompression via division or partial resection of the TCL
or external neurolysis. However, internal neurolysis as an
adjuvant procedure raises eyebrows.
Durksen [6] emphasizes the importance of external neurol-
ysis for the nerve, which must be able to glide parallel to its
neighboring tissue in different positions of the fingers or hand.
Imprisonment of the nerve in scar tissue slows axonic flow even
though endoneural structures still function.
Curtis and Eversman [7] stressed that internal neurolysis be
directed at the chronic effects of direct pressure and the relative
ischemia of the median nerve for early restoration. Further-
more, the procedure should be used only in patients with
(1) constant sensory loss, (2) thenar muscle atrophy and/or
palsy, and (8) failure to improve with TCL division. Their
results in 96 operations were 90% restoration of both sensation
and motor power.
Babcock proposed originally that internal neurolysis should
include splitting of the nerve sheath and separation of the
bundles (hersage) in order to call attention to the technique of
combing the fascicles of the nerve. He used the technique when
epineural thickening existed, supposedly to permit “the escape
of exudate from the nerve and reduce the pressure on the nerve
fibers.”’
Preserving the interfascicular plexus of nerves is of great
importance. Schlesinger and Liss stressed the posterior or dorsal
aspect of the median nerve, which should remain undisturbed
(not elevated from its bed of areolar tissue within the carpal
canal). Again, Lanz [5] emphasized the importance of ap-
proaching the median nerve from the ulnar side of the
continued longitudinal or thenar crease incision to avoid
lacerations of variant branches.

Operative Results

Phalen concluded from his observations that long-standing

paralysis of the thenar muscles usually heralded a poor and slow
CARPAL TUNNEL SYNDROME 22a

return of the abductor and opponens function, but occasionally

patients were relieved and regained thenar muscle function after
TCL division.
Love and associates similarly concluded that the more
complete the paralysis, the less likelihood of postoperative
recovery.
Kendall, in a series of 116 cases, concluded that sensory
recovery was generally good; however, motor recovery was
variable and with atrophy, recovery could not be expected.
The factors determining prognosis are variable age of
patient, duration of symptoms and EMG findings.

Complications of Surgical Release for CTS

Nearly all surgeons stress the immediate and lasting relief of

symptoms following their preferred operation, but seldom
mention the failures and complications, which are as follows:
1. Incomplete division of TCL, with symptoms and signs
persisting.
2. Damage of palmar cutaneous branch of median nerve via
the transverse incision, with a morbidity of not loss of
sensation but a painful neuroma entrapped in scar.
3. Sympathetic dystrophy (a disturbance in the autonomic
nervous system) characterized by persistent pain aggra-
vated by motion, swelling, hyperesthesia > edema and
proximal pain > cool, cyanotic skin and atrophy with
joint contracture. Stelazine and vigorous physical ther-
apy are usually effective. If not, a stellate ganglion block
may be used.
4. Hypertrophic scar secondary to poor incisional judg-
ment.
5. Damage to the superficial palmar arch via blind transec-
tion of the TCL through a limited transverse incision,
leading to a palmar hematoma and circulatory embar-
rassment.
6. Bowstringing of the flexor tendons due to a judicious
excision of the TCL restraint, leading to a significant
loss of function and requiring reconstruction of the TCL
with a free tendon graft.
7. Adherence of the flexor tendons following tenosynovec-
tomy. Removal of the synovium during CT release is
222 M. G. HALL, JR.

generally not recommended except when it is invasive or

a biopsy is necessary. Its removal causes excess bleeding
and excessive scar formation. Early motion of the digits
in a supportive bulky dressing is encouraged.
8. Painful incision due to adherence of tiny cutaneous
sensory nerves caught in the scar. This is usually relieved
by massage.
In conclusion, a controversial, common office problem has
been presented, with emphasis on the surgical anatomy, variants
of its structures, the proposed operative techniques, results and
complications. Success or failure in relieving the symptoms and
signs of CTS basically depends on the judgment and skills of the
operating surgeon.

References

1. Brain, W.R. and Wright, A.D.: Spontaneous compression of both

median nerves in the carpal tunnel: Six cases treated surgically. Lancet
MS 2aelo 4c
2. Phalen, S.: Reflections of 21 years experience with carpal tunnel
syndrome. JAMA 212:1365, 1970.
3. Paget, J.: Lectures on Surgical Pathology. Philadelphia:Lindsay and
Blakiston, 1854, p. 42.
4. Entin, M.A.: Carpal tunnel syndrome and its variants. Surg. Clin. North
Am. 48:1097, 1968.
5. Lanz, U.: Anatomical variations of the median nerve in the carpal
tunnel. J. Hand Surg. 2 (suppl. 1):44-53, 1977.
6. Durksen, F.: Anomalous lumbrical muscles in the hand. A case report.
J. Hand Surg. 3 (supp. 6):550, 1978.
7. Curtis, R.M. and Eversmann, W.W.: Internal neurolysis as an adjunct to
the treatment of the carpal-tunnel syndrome. J. Bone Joint Surg.
55-A:733-740, 1973.

Bibliography
Butler, B.J. and Bigley, E.C.: Aberrant index (first lumbrical tendinous
origin) associated with carpal tunnel syndrome. J. Bone Joint Surg.
53-A:160-162, 1971.
Cseuz, K.A., Thomas, J.E., Lambert, E.H. et al: Long term results of
Operation for carpal tunnel syndrome. Mayo Clin Proc. 41:232-241,
1966.
Das, S.K. and Brown, H.G.: In search of complications in carpal tunnel
decompression. Hand 8:243-249, 1976.
Doyle, J.R. and Carroll, R.E.: The carpal tunnel syndrome. A review of
100 patients treated surgically. Calif. Med. 108:581-584, 1963.
CARPAL TUNNEL SYNDROME Deo

Eversmann, W.J. and Retseck, J.A.: Intraoperative changes in motor nerve

conduction in carpal tunnel syndrome. J. Hand Surg. 3:77-81, 1978.
Jabaley, M.E.: Personal observations on the role of the lumbrical muscle in
carpal tunnel syndrome. J. Hand Surg. 3 (suppl. 1):82-84, 1979.
Lanzer, R.C.: The carpal tunnel syndrome. Clin. Orthop. 15:171-179,
1958.
MacDonald, R.I: Complication of surgical release for carpal tunnel
syndrome. J. Hand Surg. 3 (suppl. 1):70-76, 1978.
Tonbarg, J.A.: Carpal tunnel syndrome caused by an abnormal distribu-
tion of the lumbrical muscle. Scand. J. Plast. Reconstr. Surg. 4:72,
1970.
Schultz, R.J., Endler, P.M. and Huddleston, H.D.: Anomalous median
nerve and anomalous muscle belly of the first lumbrical associated
with carpal tunnel syndrome. J. Bone Joint Surg. [Am.]
55:1744-1746, 1973.

, Self-Evaluation Quiz

1. Which two tests are most appropriate in the evaluation of

carpal tunnel syndrome?
a) Kaplan
b) Phalen
c) Wright
d) Allen
e) Tinel
2. Which of the following complications is most common
following carpal tunnel release?
a) Incomplete division of the transverse carpal ligament
b) Sympathetic dystrophy
c) Damage of palmar cutaneous branch of median nerve
d) Hypertrophic scar
3. Which of the following does not form the carpal tunnel?
a) Hamate
b) Trapezium crest
c) Pisiform bone
d) Capitate
e) Styloid process of radius
4. Median nerve palsy is associated with which of the
following?
a) Adson test
b) Wrist drop
c) Froment sign
d) Interference with thumb mobility
224 M. G. HALL, JR.

5. The most frequent cause of median nerve compression is:

a) Hypertrophied palmaris longus
b) Nonspecific tenosynovitis
c) Colle fracture
d) Aberrant lumbrical muscle
e) Aberrant flexor digitorum sublimis
6. What procedure should be done in addition to division of
the transverse carpal ligament for patients with carpal
tunnel syndrome who have thenar muscle atrophy?
a) Electromyography
b) Huber procedure
c) Internal neurolysis
d) Immobilization

Answers on page 527.

 Compression Syndromes
Edward A. Rankin, M.D.

Objectives
This paper will explain the pathogenesis of syndromes
of peripheral nerve compression and will discuss the
diagnosis of these conditions. The reader should gain an
understanding of the recognition and management of these
problems.

The most frequently encountered peripheral nerve com-

pression or entrapment is the carpal tunnel syndrome. In
addition to compression of the median nerve in the carpal canal,
it may be entrapped at other points along its course. Likewise,
the ulnar and radial nerves may be compressed at various points
along their course. The occurrence of peripheral nerve compres-
sion or entrapment, with the exception of the carpal tunnel
syndrome, is the focus of this paper.
The entrapment or compression of a peripheral nerve may
be secondary to anatomic variations, swelling, edema, inflamma-
tion, scar tissue or mechanical factors. The peripheral nerves are
particularly vulnerable to compression at certain points along
their anatomic course.

Median Nerve Compression,

Excluding the Carpal Canal

The median nerve may be compressed between the two

heads of the pronator teres. These patients present the picture
of the carpal tunnel syndrome, with several exceptions. Pain
and tenderness are present in the proximal forearm anteriorly.
The Tinel sign, when present, is likewise at the site of nerve
irritation proximally, as opposed to the wrist level in the case of

Edward A. Rankin, M.D., F.A.C.S., Private Practice, Washington, D.C.

225
 E. A. RANKIN
226

for the
carpal tunnel syndrome. Phalen’s test is negative
aforementioned reason.
Electrodiagnostic studies, specifically nerve conduction ve-
locities, when confirmatory, will show delayed latency across
the proximal forearm (level of compression) and not the wrist,
as would be seen with carpal tunnel syndrome.
Anterior interosseous syndrome presents a classic picture.
The anterior interosseous is a motor branch of the median nerve
innervating the flexor pollicis longus, the profundus to the
index and long fingers and the pronator quadratus. Paralysis in
the thumb and index long flexors gives a characteristic flat
pinch (inability to flex the distal joints). Other than trauma,
Spinner [1] gives the following causes for anterior interosseous
syndrome: a tendinous origin of the pronator teres or flexor
superficialis, thrombosis of the ulnar collateral vessels, aberrant
radial vessels and accessory muscles. In pronator and in anterior
interosseous syndrome, exploration and nerve decompression
are indicated.
Ulnar Nerve

Pressure on the ulnar nerve can cause clawing of the small

and ring fingers, especially if the compression is distal (low) in
the ulnar nerve. Sensation may be decreased or absent in the
small finger and the ulnar half of the ring finger. Prolonged or
severe compression in the ulnar nerve will cause atropy of
innervated muscles. This is particularly noted in the first dorsal
interosseous muscle. The Froment sign may be present in ulnar
nerve palsy (flexion of the thumb IP joint and hyperextension
of the MP joint with forced active adduction of the thumb to
the second metacarpal).
The ulnar nerve may be entrapped at the elbow (cubital
tunnel) or the wrist (Guyon’s canal). Spinner [1] cites the
following causes of entrapment or compression of the ulnar
nerve at the elbow: thickening of the fascial connection of the
flexor carpal ulnaris, ganglion cyst, anomalous muscles, hyper-
trophic arthritis, nonunion of medial epicondylar fractures,
rheumatoid synovitis (elbow joint), cubitus valgus, supracon-
dyloid process and recurrent subluxation or dislocation of the
ulnar nerve.
Traditional treatment for tardy ulnar nerve palsy has been
anterior transposition of the ulnar at the elbow. In some cases
COMPRESSION SYNDROMES 227

where the entrapment is due to thickening of the fascial

connection between the two heads of the flexor carpi ulnaris,
lysis or excision of the aponeurosis may be sufficient treatment.
Anterior transposition of the ulnar nerve should be performed if
the palsy is due to significant cubitus valgus, a subluxating or
dislocating nerve or a poor bed posteriorly (cubital tunnel).
When anterior transposition of the ulnar nerve is performed, it
seems less subject to continued irritation if it is placed deep to
the common flexor muscles [2].
Compression of the ulnar nerve distal to the wrist in
Guyon’s canal was first reported as a clinical entity in 1965 [3].
The ulnar compression neuritis at the wrist may be caused by
chronic irritation due either to repetitive heavy manual work or
to occupational pressure on the hypothenar eminence. An
example of the latter is crutch walking. Other causes of
compression may be space-filling lesions such as a ganglion,
rheumatoid synovitis, tenosynovitis, osteoarthritis and throm-
bosis of the ulnar vessels in Guyon’s canal.
The symptoms of ulnar neuritis at the wrist are pain in the
wrist, with numbness, tingling and paresthesias in the small and
ring (ulnar half) fingers. Most often, motor signs and symptoms
are absent [3]. This condition may occur in conjunction with
the carpal tunnel syndrome.
Treatment for entrapment of the ulnar nerve in Guyon’s
canal is surgical release of the ulnar carpal ligament, along with
removal of any space-occupying abnormal tissue.

Radial Nerve

Compression of the radial nerve in the musculospinal groove

may occur on a one-insult basis, as in the so-called Saturday nite
palsy. This injury to the nerve recovers and the definitive
treatment is simply to allow time for recovery. In some cases,
dynamic extension splinting may be indicated.
The radial nerve may be compressed at the lateral inter-
six
muscular septum. Lack of recovery of nerve function after
suspect ed at this level should
weeks when compression is
indicate possible surgical exploration. Electromyographic
studies can help establish a baseline .
me is
The dorsal (posterior) interosseous nerve syndro
e of the hand with posteri or
especially interesting. The postur
228 E. A. RANKIN

interosseous nerve paralysis is typical. The patient can dorsiflex

the wrist and can extend the fingers at the interphalangeal joints
(by way of the lumbricals, median and ulnar nerve innervation),
but not at the metacarpophalangeal joints (extensor digitorium
communis).
Spinner [1] found a fibrous arch (arcade of Fréhse) in 30%
of adult specimens (50 arms) through which the posterior
interosseous nerve entered the supinator muscle. The presence
of this arch increases the possibility of nerve compression.
Ganglion cysts, fatty tumors, radial head fractures and rheuma-
toid arthritis have caused compression of the posterior inter-
osseous nerve. Lack of signs of recovery after six to eight weeks
should raise the question of surgical exploration if compression
of the nerve is suspected.
Radial tunnel syndrome, first described by Roles and
Maudsley [4] and later by Lister et al [5], has been suggested
as a cause for “‘resistant tennis elbow.” These patients complain
primarily of pain, which is usually well localized to the extensor
mass just below the elbow and is of an aching nature. Weakness
of grip may be present, and the pain is initiated and intensified
by repetitive movements of pronation and wrist flexion. Lister
cites three pathognomonic signs in the radial tunnel syndrome:
1. Tenderness to palpation, most severe over the radial
nerve in the muscle mass at and just distal to the radial
head.
2. Resisted extension of the long finger with the elbow
extended, producing pain in the area of tenderness.
3. Pain in resisted supination of the extended forearm.
Surgical decompression in the majority of these cases has been
successful.

Summary

Peripheral nerves may become compressed or entrapped

along their course. The clinical picture may be obvious or quite
subtle. Ongoing compression may lead to progressive problems
with pain and affect the normal motor and sensory function of
the nerve. Once such diseases as cervical arthritis, ruptured
cervical discs, spinal cord tumors, neurologic disorders, thoracic
outlet syndrome and peripheral neuropathy are ruled out,
surgical exploration and nerve decompression may be indicated.
COMPRESSION SYNDROMES 229

References

1. Spinner, M.: Injuries to the Major Branches of Peripheral Nerves in the

Forearm. Philadelphia:W. B. Saunders Co., 1972.
2. Broudy, A.S., Leffert, R.D. and Smith, R.T.: Technical problems with
ulnar nerve transposition at the elbow: Findings and results of
reoperation. J. Hand Surg. 3 (1):85, 1978.
3. Dupont, C., Cloutier, G.E., Prevost, Y. and Dion, M.A.: Ulnar-tunnel
syndrome at the wrist. J. Bone Joint Surg. 47:757, 1965.
4. Roles, N.C. and Maudsley, R.H.: Radial tunnel syndrome: Resistant
tennis elbow as a nerve entrapment. J. Bone Joint Surg. 54B:499,
O72.
5. Lister, G.D., Belsole, R.B. and Kleinert, H.E.: The radial tunnel
syndrome. J. Hand Surg. 4:52, 1979.

Self-Evaluation Quiz

1. A 45-year-old, right-handed carpenter complains of tingling

in the right thumb and index fingers. He has no thenar
atrophy but has Tinel’s sign in the proximal anterior
forearm. Cervical spine examination and x-ray films are
normal. He most likely has:
a) Radial tunnel syndrome
b) Cervical arthritis
c) Neurolemmoma
d) Pronator syndrome
e) Albright syndrome
2. Persistent and recalcitrant “tennis elbow” may be due to:
a) Carpal tunnel syndrome
b) Radial tunnel syndrome
c) Ulnar tunnel syndrome
d) All of the above
e) None of the above
3. The ulnar nerve may be entrapped in:
a) The cubital tunnel
b) The carpal tunnel
c) Guyon’s canal
d) Both aandb
e) Bothaandc
4. A 35-year-old housewife complains of inability to extend
but
the fingers in her left hand fully. She can extend the IP
has:
not the MP joints. Wrist extension is normal. She likely
a) Carpal tunnel syndrome
b) Radial tunnel syndrome
230 E. A. RANKIN

c) Anterior interosseous syndrome

d) Posterior interosseous syndrome
e) None of the above

Answers on page 527.

 Trigger Fingers
and de Quervain Disease
B. Scott Teunis, M.D. and Norman J. Cowen, M.D.

Objective
The objective of this presentation is to acquaint the
reader with the details regarding chronic stenosing teno-
synovitis of the wrist and fingers. Emphasis is placed on the
limited use of injectable water-soluble steroids in the acute
cases and the necessity of thorough familiarity with the
anatomy involved by the operating surgeon.

Trigger finger is characterized by locking and snapping of

the digit. There is pain, tenderness and thickening of the sheath.
Trigger fingers and de Quervain disease involve a process called
chronic stenosing tenosynovitis. As far as the causes are
concerned, repetitive trauma is probably the greatest one. Often
the rheumatoid patient will have this condition as part of his
syndrome, and sometimes as a presenting symptom. Therefore,
patients deserve consideration of a rheumatoid work-up when
they present with a trigger finger or de Quervain disease. The
condition is essentially a mechanical problem. If you think of
the tendon and its surrounding sheath, it is like a piston in a
cylinder. The cylinder (sheath) stenoses, thickens and starts to
a
impede the glide of the piston (tendon). As this takes place
and
swelling on the tendon develops proximal to the stenosis
triggering occurs. It may be compared to a clothesline when
pulley. The
there is a knot in the line and it passes through the
the body,
triggering can occur in any tendon anywhere in
ites (Site oe SY 2 Se Se
and Norman J.
B. Scott Teunis, M.D., Hand Surgeon, McLean, Va.;
Washing ton, D.C.; Presiden t and Chairman,
Cowen, M.D., Hand Surgeon,
of Director s of the National Hand Researc h and Rehabilitation
Board
ty Rehabilitation Clinic,
Fund, Inc.; Consultant, National Upper Extremi
Washington, D.C.

231
232 B. S. TEUNIS AND N. J. COWEN

although it is much more common in the wrist and fingers,

where there is a directional change.
There is a female:male occurrence ratio of over 10:1. The
female preponderance is especially true in de Quervain disease.
Some people think this is due to the greater mobility of the
multangular bone in the female. Repetitive trauma is a frequent
accompanying cause. It also occurs in workers, such as
carpenters, who do the same thing for several hours a day, i.e.
repeat the same motion. Another example would be the
housewife who stacks or irons large amounts of laundry.
In de Quervain disease the first dorsal compartment is the
area of concern, whereas in trigger finger most of the triggering
occurs in the distal palm. It is where there is a thickened pulley.
The abductor pollicis longus and the extensor pollicis brevis are
the tendons involved in de Quervain disease. There is a
tremendous variability in anatomy in this area. The abductor
pollicis can insert in the multangular or into the base of the first
metacarpal. Often, it is a double tendon. There may be as many
as eight separate slips in all. The extensor pollicis brevis tendon
can be absent, hypoplastic or present in a separate compart-
ment. This variability is a critical factor when one is considering
surgical decompression.
The diagnosis is not very difficult. The patient presents with
pain, and there is tenderness over the radial styloid. The
Finkelstein test will be positive. This is elicited by clasping the
flexed thumb with the fingers and then deviating the wrist
toward the ulna. Intense pain occurs over the radial styloid in a
positive test. De Quervain disease can be confused with
carpometacarpal osteoarthritis. In the latter, however, the
tenderness is over the carpometacarpal joint and not over the
radial styloid. A tenosynovitis of the flexor carpi radialis tendon
must also be ruled out. Occasionally the tendon sheath can get
so thickened that it will masquerade as a ganglion over the
radial styloid.
In the treatment of these entities, we would like to
emphasize the use of water-soluble steroids. One should avoid
use of the suspensions, as there are considerable problems with
depigmentation and atrophy with these forms. Steroid injection
is not innocuous. One can cause problems for the patient by
injecting the wrong level of tissue. One should not get it into
the radial cutaneous nerve or into the fatty tissue, for this will
TRIGGER FINGER/DE QUERVAIN DISEASE 233

cause additional problems. We think steroid injection should be

limited to the acute case with about 48 hours of splinting.
In de Quervain disease and trigger fingers, we should think
basically of a surgical approach to management, except in the
acute case. In the former, the incision should be transverse in
order to avoid crossing the axis of the wrist at an unfavorable
line and thereby producing hypertrophic scar. Exchanging
complete relief of symptoms for a hypertrophic scarring which
will bother the patient afterward is a bad trade-off. The
ligament is exposed as it courses over the radial styloid. There
has been discussion about whether or not to excise this entirely
or to incise it. Sometimes, radical excision will disrupt the angle
to the point where these tendons will sublux volarly, which can
be a problem. With the first compartment opened, tendons
should «be separated. Make sure that all fibrous septa are
divided. The most common cause of recurrent problems
involving pain is failure to either incise or completely divide all
the septa in this compartment. One must find two tendons of
unequal caliber in order to be sure that both the extensor
pollicis brevis and the abductor pollicis longus have been
released. Otherwise one may have released two slips of the
abductor pollicis longus and the extensor may still be hidden in
a separate compartment! It is important to identify the digital
bundles to be certain that they are protected. At the wrist,
avoid disturbing the sensory branches of the radial nerve as they
may get caught in the scar. Certainly protect them. Close only
the skin. Always use tourniquet control. Mild tenderness over
the scar usually, but not always, resolves with gentle massage
after the wound is healed. In diabetics an increase in the
recurrence rate and in nerve irritation can be anticipated.
In conclusion, de Quervain disease and trigger fingers are
readily diagnosed. Limited use of steroids should be considered
in the acute case. Surgical decompression is a relatively simple
procedure and complications are few.

Self-Evaluation Quiz

1. Stenosing tenosynovitis is a rare condition affecting the

wrist and fingers.
a) True
b) False
234 B. S. TEUNIS AND N. J. COWEN

2. Rheumatoid arthritis rarely presents with symptoms of

stenosing tenosynovitis of the fingers and wrist.
a) True
b) False
3. The median nerve is most commonly injured during surgical
decompression of de Quervain disease.
a) True
b) False
4. Stenosing tenosynovitis often occurs where there is a
directional change in the tendons.
a) True
b) False
5. Depigmentation and fat atrophy can occur with the use of
injectable steroids.
a) True
b) False
6. The radial cutaneous nerve lies directly subjacent to the
incision used in surgical decompression for de Quervain
disease.
a) True
b) False
7. Surgical treatment of de Quervain disease and trigger finger
is unpredictable and yields poor results.
a) True
b) False
8. Women are more frequently affected than men with de
Quervain disease.
a) True
b) False

Answers on page 527.

 The Sensory Neuroma —
Its Prevention
William H. Bowers, M.D.

Objective
A major problem in the practice of hand surgery is the
painful posttraumatic sensory neuroma. This paper centers
on the prevention of this complication, where possible. A
discussion of pathogenesis, major contributing factors, and
nerves at risk provides the theoretical knowledge for
accomplishing this objective.

A complication of surgery in the upper extremity is the

painful posttraumatic sensory neuroma.
A neuroma is a proliferative nonneoplastic mass formed at
the site of traumatic disruption or crush of neural axons and
Schwann cells. Pathophysiologically, a neuroma is a predictable
result of the neural response to injury. In the proximal segment,
wallerian degeneration occurs distal to the node of Ranvier,
while axons are also disappearing in the area of the nerve distal
to the injury. Central cell changes occur. Nerve conduction is
not possible through the area of injury. Axonal regeneration
begins proximally even as the degenerative process is evolving.
The regenerating Schwann cells divide and enlarge as axons
sprout in the neural tube. The injury gap becomes filled with
the supportive cells. Axons attempt to follow their previous
course across the injury site but encounter a maze of relative
blockages and dead ends. Some axonal sprouts may find their
way in tortuous courses through the barrier, some double back
on themselves and others simply terminate. The result is a tangle
of axons, Schwann cells and fibrocytes. The physical nature of
eee We is Beane oh ee
ic
William H. Bowers, M.D., Chief, Hand Section, Division of Orthoped
School of Medicine at Chapel Hill.
Surgery, University of North Carolina

235
236 W. H. BOWERS

the neuroma depends on whether the nerve was completely or

partially transected and, if transected, on how far apart the
nerve ends retract. There may thus be a terminal neuroma or a
neuroma in continuity — either partial or complete.
Why are some neuromas painful? Neuromas are, at least
technically speaking, part of every nerve injury — excluding the
possibility of a perfect reanastomosis. If so, then why are some
a problem and others not, especially when the two are
histologically identical? A wealth of clinical experience has
suggested that location is probably the major determining
factor. Most painful neuromas are superficial in location, often
associated with adherent scars or with thin covering skin, near
unprotected bony prominences and, on many occasions, present
in high-impact zones such as the palmar contact areas in fingers
or in amputation stumps. A second determining factor may be
the physical character of the neuroma itself. Studies with
silicone capping imply that when the size of the neuroma is
controlled in the treatment of an already painful neuroma, the
new neuroma may be less painful.
How much pain is involved? The spectrum of neuroma
complaints vary from mere annoyance to incapacitating pain
and the reflex dystrophies with their sequelae of amputation
and economic disaster.
A simple review of the 30 or 40 proposed treatment
methods serves to illustrate the ongoing concern of both the
surgeon and the patient with this problem. The best “‘treat-
ment”? remains prevention or alleviation of the observed
conditions associated with painful neuromas. It is on this
contention that the remainder of these comments focus.
Perhaps the major problem with the painful neuroma occurs
in those resulting from crush or amputation of the digits. The
digital nerve as it courses through the narrow digital tube is
both superficial and near to bony condyles, moving joints and
tendons. Scarring is unavoidable in areas of injury and the
palmar digital theca is an impact zone. One wonders why all
nerve injuries here are not painful. We walk a thin and
ill-defined line in the handling of these nerve ends. Amputation
neuromas cannot be avoided but careful resection of the nerve
and its ramifications well back of the area of tip scarring, which
will occur, may help in avoiding this problem. Amputations
SENSORY NEUROMA Dro

near the joint call for resection of the next proximal condyles
to provide a less bulbous and softer tip with less opportunity
for the nerve to become trapped in the skin-bone sandwich.
The neuromas which result from iatrogenic injuries to nerve
are no less a problem, but less excusable. Here, a thorough
knowledge of anatomy and its propensity to be variable within
limits is essential. Elective incision should obviously be planned
to completely avoid the neural course when possible or, when
this is not possible, to expose it sufficiently to allow gentle
retraction.
Sensory nerves at risk in the hand-wrist area are:
1. The palmar cutaneous branch of the median nerve. This
begins from the radial side of the median nerve 1 to 2 inches
proximal to the wrist crease and proceeds to supply the skin
over the proximal thenar eminence. It crosses over the
prominence of the scaphoid tubercle and is here at risk by
incisions swung radially into this area. Its variations are
common. It may supply the sensory area on the hypothenar
eminence, beginning from the ulnar aspect of the median nerve,
or it may cross over the median nerve from the ulnar aspect to
supply the standard area. Operations which place the palmar
cutaneous branch of the median nerve at risk are several.
Incisions of notable importance are the transverse incision to
release the carpal tunnel and zig-zag incisions through this area.
It is particularly important to avoid transfixing this nerve with a
suture when closing the skin incision.
2. The sensory branches of the superficial radial nerve. The
anatomic course of this nerve is well described. Operations
which particularly place these nerve branches at risk are the
various incisions for release of stenosisng tenosynovitis (de
Quervain disease). More than one branch may be at risk.
Particularly to be deplored, from an exposure standpoint, is the
unsightly longitudinal incision. Other procedures which place
this nerve or its branches at risk are the dorsoradial approaches
to the carpometacarpal joint of the thumb or the scaphoid and,
more distally, exposures for repair of the ulnar collateral
ligament of the thumb MP joint.
3. The dorsal branch of the ulnar nerve. This nerve begins
to leave its parent some 2 to 3 inches proximal to the ulnar
styloid and spirals around the ulnar aspect of the wrist at
238 W. H. BOWERS

approximately the level of the styloid. It may be more proximal

or distal, however. It is here both superficial and adjacent to the
bony prominence of the distal ulna. It is also nearby to the
course of many tendons commonly used for transfer. Therefore,
it is at risk in the operations for resection of the ulnar head (the
so-called Darrach procedure) for ganglion excisions, dorsal
tenosynovectomy and fixation of a distal ulnar fracture.
The last example is less common but nevertheless one to be
aware of. This is injury to the volar cutaneous branch of the
ulnar nerve at the wrist. Its course is superficial and overlies the
prominence of the hamate. This branch is most often injured in
ganglion excisions, lacerations, amputations or opponensplasty
using the insertion of the flexor carpi ulnaris as a pulley. Ray
amputations particularly place at risk the two marginal sensory
nerves of the hand, for they are usually injured by longitudinal
suture entrapment.
In review, the avoidance of sensory neuroma is best
accomplished by awareness of the problems of sensory neu-
roma, awareness of the anatomy of the digital nerves involved,
and careful planning of incisions either to avoid the distribution
completely or to expose sufficiently in order to retract nerves
gently. One should not repair accidental transections of these
branches unless they supply essential areas for sensory input.
All repairs should be done with microsurgical technique.
Resection, as a treatment, should be sufficient to allow the
nerve to lie in a low-risk area according to the parameters
previously mentioned.

Self-Evaluation Quiz

1. A neuroma is the inevitable result of a nerve disruption.

a) True
b) False
2. Following nerve injury, which processes occur in the nerve
cell?
a) Axonal degeneration (wallerian)
b) Axonal regeneration
c) Schwann cell proliferation
d) Central cell changes
3. Painful neuromas are histologically distinct from those that
are not painful.
SENSORY NEUROMA 239

a) True
b) False
4. The major determinant in the occurrence of painful
neuroma is:
a) Location
b) Size
c) Time since injury
d) Associated neurosis
5. The location of a painful neuroma is typically:
a) Superficial
b) Near adherent scars
c) Near bony prominences
d) In impact zones of the hand
6. Digital amputations are rarely associated with symptomatic
posttraumatic neuromas.
a) True
b) False
7. One technical feature of help in avoiding the symptomatic
digital amputation neuroma is:
a) Sharp section of the nerve as far distal as possible
b) Flap closure of open-tip amputations
c) Resection of condylar prominences when the level of
election is near a joint
d) Split-thickness closure of the open wound
8. The palmar cutaneous nerve is at risk in operations for:
a) Carpal tunnel release
b) Volar flexor tenosynovectomy
c) The common wrist ganglion
d) De Quervain disease

Answers on page 527.

v}
 Treatment of Painful
Amputation Stumps
John S. Gould, M.D.

Objectives
1. To delineate the various etiologies for painful amputa-
tion stumps.
2. To describe conservative modalities and surgical maneu-
* vers utilized in the management of the painful amputa-
tion stump.

The management of painful amputation stumps initially

requires a determination of the etiology of the pain. There may
be one or several sources for the problem, including poor
surface cover, bony prominence, vascular insufficiency, painful
neuromata and reflex sympathetic dystrophy — either localized
or as part of a generalized syndrome with the amputation stump
as the trigger. Once the cause of the problem is determined, a
sequence of maneuvers may be undertaken to correct the
difficulty.

Poor Surface Cover

When a poor surface covers the amputation stump, this

alone, or in combination with other underlying problems such
as neuromata and vascular insufficiency, may be the cause of
pain. As often as not, however, poor surface cover alone is
nonpainful, yet annoying in that surface breakdown occurs
readily. Restoration of a good surface will not only correct this
problem but also may be good management for other under-

dic Surgery;
John S. Gould, M.D., Associate Professor of Orthopae
Medical Center,
Chief, Section of Hand Surgery, University of Alabama
Birmingham.

241
242 J. S. GOULD

lying difficulties. Initially, protective devices fashioned by

competent hand therapists may be sufficient. These may be
fabricated from thermoplastic materials and can provide a
simple and inexpensive solution.
If conservative management is not adequate, a variety of
local flaps may be utilized to solve the problem. The lateral and
volar V-Y flaps are frequently sufficient. Unfortunately, they
can usually only be advanced about 1 cm. Local transposition
flaps are also helpful with the donor site, in a lower contact
area, covered with full-thickness graft. There are several good
sites for the full-thickness graft. The hypothenar eminence, for
instance, provides excellent color and texture matching, as well
as use of the wrist, elbow and inguinal creases. For the thumb
and index fingers, a flap taken from the edge of the thumb web
can provide good cover. A long volar flap can be used to cover
the tip of the thumb, mobilizing skin, soft tissue and neuro-
vascular bundles from the flexor sheath mechanism. In children,
the advancement may be accompanied by flexion of the
interphalangeal joint and subsequent splinting after healing. In
adults, this technique is not advisable but may be modified to
include a more proximal transverse incision which is widened as
the flap is advanced; the gap is then filled with a full-thickness
graft.
Revision of the stump to a more proximal level, with or
without full-thickness grafting, is a ready solution when the
additional length of the stump is not functional. This should
not be done on the thumb, where length is particularly critical.
In general, in manual laborers, we have tried to maintain at least
half of the proximal phalanx of the index finger for use in grip.
Nevertheless, if it is painful and the situation unsolvable, the
stump is a detriment to function. We do not like to revise
stumps to create a “hole in the palm” as well. The use of
palmar, cross-finger and distant flaps is generally ill-advised. The
palmar flaps are notorious in adults, for subsequent flexion
contractures in the interphalangeal joints as well as painful scars
in the palm. The cross-finger flap, although often feasible and
cosmetically attractive, may be similarly fraught with the
hazard of joint stiffness. Distant flaps may be a solution, but
the cover provided is often unsightly, with a poor color and
texture match and poor sensation. Although this is popular in
some circles, I feel it is a second-rate solution.
PAINFUL AMPUTATION STUMPS 243

Bony Prominence

Bony spurs are not necessarily painful, but may cause

overlying skin breakdown. Simple excision or revision of the
stump is the most straightforward and reliable solution. It is
essential, however, to rule out other causes of pain before
assuming that a bone spur is the problem. More often than not,
an entrapped neuroma is the true etiology.

Vascular Insufficiency

Amputation managed by replantation, avulsion injuries and

crushing injuries in which the part involved survives may be
painful because of vascular insufficiency. Often, the part may
appear essentially normal but the problem is manifested by cold
intolerance. When this occurs, simple devices such as a mitten or
a hand warmer may be sufficient for the cold months. If the
involved part is particularly critical, such as the thumb or the
entire hand, these devices should be considered primarily. Other
solutions include revascularization, particularly for a critical
part, or revision to a more proximal level. Trophic changes,
to
including atrophy of the pulp, narrowing of the part, failure
regrow a nail and loss of rugal pattern, may indicate that
amputation or revision to a more proximal level is the treatment
of choice, particularly when the painful symptoms are constant
which is
and increased by cold. Reflex sympathetic dystrophy,
should also be considered in these
a neurovascular problem,
t may be directed toward this entity
cases and initial managemen
Simple amputation may not be suf-
(see discussion below).
ficient to resolve this problem.

Management of Neuromata
of a nerve.
Neuromata always form following transection
primarily related to
When the nerve is sensory or mixed, pain is
or subcutaneous or
location. If the neuroma is in a contact area
management may be
entrapped in scar, it is often painful. Initial
of the transcutaneous
nonsurgical, including desensitization, use
and tincture of time.
nerve stimulator, protective devices
singly textured tactile
Desensitization is the application of increa
ensitivity. The sequence
stimuli to decrease or relieve the hypers
and progresses through
of stimuli begins with a cotton ball
244 J. S. GOULD

velvet or flannel, a heavier cotton material, a dry wash cloth,

burlap and, finally, sand paper. Various household items such as
uncooked rice, macaroni, pebbles and the like may be substi-
tuted. The stimulus should be applied initially to elicit only the
slightest hypersensitivity. Stroking of the sensitive part should
be carried out from proximal to distal for a specified number of
applications. Cross-wise stroking is similarly carried out in a
prescribed fashion. This activity is repeated three to four times
each day, with the patient proceeding from one material to the
next in the series, as tolerated.
When desensitization or the use of other modalities,
including the transcutaneous nerve stimulator, is unsuccessful,
surgical management should be considered. The possible ap-
proaches include excision of the neuroma, excision with
placement in a noncontact area, silicone capping with or
without placement in a noncontact area, repair with grafting,
excision with application of a flap and, when all else fails in a
larger mixed nerve, the direct implantation of a polarized
electrode. Simple excision allows the nerve to retract under
muscles or to a minimal contact area. An alternative is simply to
reposition the nerve in an area less inclined to be touched, such
as the digital web. Silicone capping involves suturing the end of
the nerve, usually after the neuroma has been excised, to the
interior of a silicone cap, which may then be redirected into a
noncontact area. This device avoids scar entrapment of the
neuroma. The ideal solution lies in surgical repair with grafting,
since this has particular application in the superficial radial
nerve and the palmar cutaneous branch of the median nerve,
both of which are notorious for persistent symptomatology.

Neuromata Series

From July 1975 through March 1979, we surgically

managed 56 digital neuromata, 8 neuromata of the superficial
radial nerve, 1 of the dorsal cutaneous branch of the ulnar
nerve, 3 of the ulnar nerve and 3 of the median nerve. In the
series managed by simple excision with retraction of the nerve,
one median neuroma became totally asymptomatic and two had
mild but tolerable symptoms. Of those affecting the ulnar
nerve, two were pain-free and one had mild symptoms. The
problem in the dorsal cutaneous branch of the ulnar was totally
PAINFUL AMPUTATION STUMPS 245

relieved by simple excision. The one superficial radial nerve

managed in this way had mild symptoms. Twenty-nine of the
38 digital neuromata were totally relieved by simple excision, 3
had mild symptoms, and 6 had persistent and intolerable pain.
Of seven superficial radial neuromata managed with silicone
capping, four were asymptomatic and three had mild, tolerable
pain. Of 14 digital neuromata, 6 of which had had a failed
excision, 12 were asymptomatic following capping and 2 had
mild, tolerable pain. Two superficial radial nerves with specific
placement in noncontact areas had total relief, as did two which
were capped and placed in a noncontact area. Eight digital
neuromata placed in the digital webs were totally asympto-
matic, and four that were capped and placed in the web
similarly had no pain.

Reflex Sympathetic Dystrophy

Reflex sympathetic dystrophy is usually a difficult manage-

ment problem; however, if the diagnosis can be made early,
conservative management is often successful. In many cases, the
problem includes the generalized syndrome as well as a local
the
trigger. Attention must be paid to both the trigger and
dystrophy. On occasion, simple removal of the trigger may
of the
relieve the problem. At other times, following relief
y can then be managed by conservat ive
trigger, the dystroph
occasion both the trigger and the overlying
measures. On
dystrophy require surgery.
n
Initially, sympathetic blockade with a stellate ganglio
e. This will
block utilizing a long-acting agent may be effectiv
the diagnos is, but a negativ e respons e to a block may
help with
block also
occur with a persistent trigger. Brachial or axillary
blocks to the
eliminates the sympathetic response and local
transcu taneous
involved part can be helpful. The use of the
desensitization may
nerve stimulator and physical modalities of
regional reserpine
also prove beneficial. Recently intravenous
usually give 2 mg of
has been employed in our patients. We
with the tourniquet
reserpine and 30 cc of 0.5% xylocaine
ment has often been
inflated for 20 to 30 minutes. This manage
two to three months , or
found to be effective for periods of
used prophyl actical ly
indefinitely in some cases. It has been has
a prior syndro me and
when operating on a patient with
246 J. S. GOULD

retrieved surgery in which the patient postoperatively mani-

fested a flare. Relief of the trigger should always be considered
early in management, but dorsal sympathectomy may also be
needed.

Conclusion

The etiology of the painful amputation stump should

always be determined as an initial step in management.
Conservative measures for each of the entities may be utilized,
although a number of sequential surgical maneuvers may be
required for final relief. Long-suffering patients with painful
amputation stumps deserve rapid, definitive and decisive treat-
ment.

Self-Evaluation Quiz

1. The etiology for a painful amputation stump may be:

a) Poor surface cover
b) Bony prominence
c) Vascular insufficiency
d) Neuromata
e) Reflex sympathetic dystrophy
f) All of the above
2. Poor surface cover alone is usually painful.
a) True
b) False
3. The poor surface may be remedied by all of the following
techniques except:
a) Local flaps
b) Distant flaps
c) Full-thickness grafts
d) Split-thickness grafts
e) Revision to a more proximal level
4. Management for vascular insufficiency may include:
a) Use of a hand warmer
b) Revascularization
c) Revision to a more proximal level
d) All of the above
5. Neuromata do not always form following transection of a
nerve.
PAINFUL AMPUTATION STUMPS 247

a) True
b) False
All neuromata are painful.
a) True
b) False
Desensitization refers to:
a) Surgical trimming of the nerve
b) A nonsurgical exercise
c) Electrical stimulation of the nerve
d) Chemical applications
The ideal surgical management for the painful neuroma is:
a) Simple excision
b) Silicone capping
c) Nerve repair or grafting
d) “Redirection of the neuroma into a noncontact area
Reflex sympathetic dystrophy may require:
a) Management of the “trigger”
b) Management of the overlying dystrophy
c) Both of the above
10. Relief of reflex sympathetic dystrophy may include:
a) Relief of the trigger
b) Sympathetic blockade at the stellate ganglion
c) Local nerve blocks
d) Drug therapy
e) Sympathectomy
f) All of the above

Answers on page 527.

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 Soft Tissue Tumors of the Hand
Avrum I. Froimson, M.D.

Objective

The surgeon dealing with masses and tumorous lesions

in the hand must be aware of the many possibilities in
diagnosis and treatment. This paper will present a working
classification of soft tissue hand tumors and show examples
of many that may be encountered.

Pseudotumors

The pseudotumors are the most common types of masses,

starting with the ubiquitous ganglion in its many forms.

Ganglion
The ganglion is a cyst, containing hyaluronic acid, derived
ive
from degenerated ground substance of collagen in connect
n site of origin is on the dorsum of the
tissue. The most commo
lunate ligamen t and wrist joint capsule ,
wrist from the scapho
the radial wrist extensors and finger
presenting between
extensors. Althou gh other authors have shown a few cases
joint, that is
where the ganglion communicated with the wrist
ganglion contents
usually a late occurrence in the process. The
arise on the
are distinctly different from joint fluid. Ganglia
may surround either
flexor side of the wrist less commonly and
cysts fluctuate in size
radial or ulnar artery (Fig. 1). Ganglion
is by palpation and
and may be painful or not. Diagnosis
of transillumination of light from a small
demonstration
consists first of
penlight in a darkened room. Treatment
steroid and perforation of
aspiration, injection of water-soluble
Clinical Professor of Orthopaedic
Avrum I. Froimson, M.D., Assistant
Reser ve Univer sity; Hand Surgeon, Saint Luke’s
Surgery, Case Western
Hospital, Cleveland, Ohio.

249
250 A. I. FROIMSON

FIG. 1. Ganglion.

the cyst wall. This may be repeated from time to time. Only
those cysts that recur with significant pain or large size are
surgically removed. To reduce the probability of recurrence
after excision, adequate anesthesia (general or arm block),
tourniquet ischemia and total excision of the degenerated tissue
of origin of the cyst are essential. As this is not a hernia of the
joint, the capsule need not be closed by suture after the
excision.
Smaller ‘“‘seed” ganglia arise in the fingers and palm from
the flexor tendon sheaths, the volar retinacular ganglia.
The mucous cyst is the ganglion arising from the dorsum of
the distal interphalangeal joint affected by Heberden nodes or
degenerative arthritis. The fingernail may become grooved if
this cyst presses on the germinal fingernail tissue (Fig. 2).
Underlying bony spurs should be excised if the cyst is surgically
removed. Split-thickness skin grafting may be needed to cover
the defect, as the mucous cyst thins the skin severely.

Pyogenic Granuloma
Reaction to low-grade infection of superficial tissues, skin,
subcutaneous fat and possibly joint capsule following minor
trauma can yield proliferative lesions simulating tumor (Fig. 3).
The biopsy specimen microscopically shows histiocytes and a
very vascular stroma that can suggest sarcoma. The wary
FIG. 3. Pyogenic granuloma.
 A. I. FROIMSON
252

surgeon will rely on his clinical impression of granuloma and

treat this by local excision or cauterization.

Dupuytren Disease
Before the development of diffuse palmar fascia bands or
contracture, the early nodules of this disease may cause concern
of possible tumor formation. The location of the mass, bilateral
involvement, foot nodules and family history will alert the
surgeon to the correct diagnosis. Biopsy is contraindicated, not
only because early surgery will accelerate the disease process
but also because the examined tissue may histologically
resemble fibrosarcoma, with tragic consequences.

Gigantism
Massive enlargement of one or more digits, beginning in
infancy, may cause grotesque deformity requiring substantial
excision of tissue or ablation of the part.

Aneurysm
Traumatic aneurysms of radial or ulnar artery or the palmar
arches can produce localized swelling. Diagnosis is made by
Doppler examination or arteriography.
Developmental or acquired arteriovenous malformations can
cause digital swelling. These are extremely difficult to eradicate
short of amputation of the finger.

Metabolic
The cholesterol deposits of xanthoma tuberosum multiplex
can produce gruesome finger masses that interfere with hand
function (Fig. 4). Simple local excision gets rid of these but
medical measures to lower serum cholesterol are needed to
prevent reaccumulation of material.
Gouty tophi are curretted if allopurinol does not allow
absorption.

Dejerine-Sottas Disease
A peripheral nerve may be found greatly enlarged, present-
ing as a possible tumor in this hypertrophic interstitial
neuropathy. Biopsy is unnecessary once the gross appearance is
seen at surgery and certainly excision of the nerve is contra-
SOFT TISSUE TUMORS
Ne

FIG. 4. Xanthoma tuberosum.

indicated. If the surgeon cannot exclude an intraneural mass,

the involved nerve sheath can be opened longitudinally for
inspection.

Epidermoid Cyst
Epithelial cells traumatically implanted in the palmar
tissues, especially the fingertips, can proliferate and produce
tumor swelling composed mostly of sebaceous and sweat gland
secretions. These masses are quite firm to palpation with a
central puncta or depression in the skin of the site of traumatic
puncture (Fig. 5). The mass is excised along with an overlying
ellipse of skin containing this puncta.

Benign Tumors

Benign tumors can arise in the hand from skin, fat,

synovium or tendon sheath. Tendon itself has not been found
to produce tumor.

Lipoma
Lipomas may grow quite large before the patient presents
for treatment (Fig. 6). These usually arise in the palm from
254 A. I. FROIMSON

Me

FIG. 5. Epidermoid cyst.

FIG. 6. Lipoma.
SOFT TISSUE TUMORS
255

flexor tendon sheath and, in spite of their substantial size, are

readily excised without danger of recurrence if the surgical
exposure is generous. Diagnosis is facilitated by preoperative
xeroroentgenogram showing a characteristic “ground glass”’
shadow within a distinct capsule.

Xanthoma
The benign giant cell tumor of tendon sheath or xanthoma
most frequently is found over the middle or proximal phalanx
on the flexor side (Fig. 7), arising from and often infiltrating
the flexor sheath. These grow slowly and painlessly but may
produce erosions in the underlying bone seen on x-ray.
Histologically they resemble compacted villonodular synovitis
and are always benign. Recurrence following excision is not
unusuak but recurrences remain benign.

Hemangioma
Vascular tumors may be small and superficial such as the
sclerosing angioma, easily eradicated by cauterization, or deep

FIG. 7. Xanthoma.
 A. I. FROIMSON
256

pre-
and large, defying excision. Angiography is essential in
g. Once thought to be of value in treatme nt,
operative plannin
no
radiation therapy and injection of sclerosing agents are
longer practice d.

Fibroma
Simple isolated fibromas are occasionally found and dealt
with simply and directly by local excision.
A troublesome lesion, the juvenile aponeurotic fibroma has
recently received a great deal of interest in the hand literature.
A slowly growing, invasive, fibrous tumor of the palms of the
hands, it is seen in young children or adolescents.
It is not encapsulated, making complete excision nearly
impossible without sacrifice of essential structures; so recur-
rence is common. Histologically and rarely radiographically, this
is recognized by the presence of cartilage within the fibrous
stroma, at times calcified.

Malignant Tumors

Fortunately, primary soft tissue malignancy is very rarely

seen, even in a busy hand service; for to be effective, treatment
must usually be mutilative, anathema to the reconstruction-
oriented hand specialist.

Epidermoid Carcinoma
The exception to the above is the surface lesion, epidermoid
carcinoma (Fig. 8). Seen mostly in hands exposed to foul
weather or hydrocarbons in industry, it can be cured by wide
local excision. Axillary node enlargement dictates radical
dissection there.

Malignant Melanoma
The converse of the epidermoid carcinoma is the malignant
melanoma. Recognized by the melanin staining of the tumor on
or above the surface of the skin and satellite melanin deposits,
its behavior is very aggressive. Even wide local excision and
mandatory regional node dissection frequently fail to prevent
death by wide dissemination of the tumor. New programs of
chemotherapy in the hands of oncologists offer hope of
SOFT TISSUE TUMORS
DAY

arresting the tumor’s progress after the surgeon has completed

his work.

Sarcoma
Fibrosarcomas, neural malignancies, synoviomas, rhabdo-
myosarcomas and practically every other tissue type have been
reported in the hand. Hope of cure lies in accurate early
incisional biopsy diagnosis, followed by well-planned and
-executed amputation with wide margins. Sometimes partial
hand amputation can cure the tumor (Fig. 9) and leave at least a
partly functional hand unit (Fig. 10).

Conclusion

A thorough understanding of the hand in all its complexity

is required for rational management of hand tumors. The
surgeon must anticipate all of the possibilities when approach-
ing a tumor or destructive soft tissue lesion in the hand. A
complete mastery of hand anatomy is essential in removing the
 FIG. 9. Fibrosarcoma.

FIG. 10. Hand salvage after sarcoma resection.

SOFT TISSUE TUMORS 259

tumor without undue damage to vital structures. A working

knowledge of tumor pathology and radiology and confidence in
competent colleagues in these specialties are mandatory.

Self-Evaluation Quiz

1. Split-thickness skin grafts are likely to be needed following

excision of:
a) Pyogenic granuloma
b) Volar retinacular ganglion
c) Mucous cyst
d) None of the above
2. Biopsy should be avoided in:
a) Pyogenic granuloma
b)’ Aneurysm
c) Dupuytren disease
d) Dejerine-Sottas disease
3. Benign tumors may arise from:
a) Skin
b) Fat
c) Synovium
d) Tendon sheath
e) All of the above
is:
4. A common tumor in children and adolescents
a) Lipoma
b) Xanthoma
c) Sclerosing angioma
d) Aponeurotic fibroma
to hydrocarbons or
5. A malignant tumor related to exposure
foul weather is:
a) Epidermoid carcinoma
b) Melanoma
c) Sarcoma
the
6. Chemotherapy offers hope of arresting which of
following tumors after excision?
a) Carcinoma
b) Melanoma
c) Sarcoma
d) None of the above
diagnosis and amputation
7. Cure of sarcoma depends on early
with wide margins.
260 A. I. FROIMSON

a) True
b) False
8. Pyogenic granuloma may easily be mistaken for sarcoma.
a) True
b) False

Answers on page 527.

 Outpatient Hand Surgery
The Hand Surgery Center: A New Concept

Kim L. Lie, M.D.

Objectives

1. To present the concept of an ambulatory surgical

facility specifically designed for hand surgery.
2. To present the modus operandi and clinical experience
* of such a facility.

for
Currently, most patients who require surgical treatment
to the hospital . Some
hand injuries and conditions are taken
clinic, while
patients are treated at a plant first aid station or a
doctor’ s office. Some of these
still others are cared for in the
sent to the hospital for
patients, of course, are eventually
nce, this indicate s a ‘“‘gap”’ in
further treatment. In our experie
of care and shows a need for
the present system in the delivery
an intermediate care facility.
the gap. It
The Hand Surgery Center is designed to fill
patien ts who cannot be treate d in the
provides care for those
plant first aid station or clinic, but who
doctor’s office or at the
ate facilit ies of a hospita l.
do not require the elabor
handle common
The Center is designed and equipped to
Patients with severe
injuries of the hand on an emergency basis.
al, as indicated.
injuries are transferred to a nearby hospit
an ambulatory basis; the
Elective operations are performed on
is designed for efficient
patients are not admitted. The Center
treatment. The surgical
delivery of surgical care and follow-up
area and examining
facilities are separated from the office

Hand Surgery Center, Warren, Mich.

Kim L. Lie, M.D., F.A.C.S., The
Adapted from Orthopaedic Review.

261
262 K. L. LIE

rooms. Preoperative and postoperative areas are designed solely

for the treatment of hand cases.
In comparison to hospital care, the patients are treated in a
more efficient manner with a minimum of inconvenience and
loss of time. In a recent survey of hospital emergency room
care, the admission procedures and examination of patients who
required immediate care for hand injuries frequently required in
excess of 90 minutes. For the patient who needed further
surgical treatment, additional delay ensued because of unavail-
able time in operating rooms. These patients were frequently
admitted to the hospital to facilitate further treatment. In the
Center, a patient with a hand injury receives definitive surgical
treatment within one hour.
For patients who do require elective operations on the
hand, the average stay in the hospital is three days. The
advantage of a short-stay facility is readily apparent when
compared with the cost of inpatient care in a hospital.

Ambulatory Surgical Care

Approximately 80% of all operations of the hand can be
performed on an ambulatory basis without requiring hospitali-
zation of the patient. This is true whether the procedures are
elective or emergency. These hand operations are usually of
short duration, and postoperative complaints of pain and
discomfort are minimal. The patients are carefully instructed as
to proper preoperative preparation. Upon entering the Center,
the patient is examined by competent medical personnel.
Preoperative evaluation and necessary laboratory examinations
are performed. The purpose and extent of the surgical pro-
cedures are fully explained to the patient, and he is required to
sign an operative consent form.
The patient is then asked to change from his street clothing
into a surgical gown and footwear, which are provided for him.
He then enters the surgical facility to undergo the operation.
The proper anesthetic, local or general, is administered after
consideration of the patient’s condition and the necessary
surgical procedure. Nonexplosive, nonflammable gases are used
for general anesthesia. Local anesthesia is augmented by
pain-relieving medication. Following the surgical procedure, the
patient is sent to the recovery area and subsequently discharged
OUTPATIENT HAND SURGERY 263

from the Center after he is fully alert. The patient carries his
recently operated hand in a sling and is usually able to go home
within a few hours following the operation. However, he is not
permitted to leave the Center by himself, but must be
accompanied by a relative or friend. He receives full instructions
concerning postoperative follow-up care, and medication for
relief of pain and discomfort is provided when necessary.
For those patients with an acute hand injury, immediate
surgical treatment under proper anesthesia is provided. If a local
anesthetic is used, the patient is permitted to return to his place
of employment; if general anesthesia is used, the patient should
not return to work until the following day.
If there are unforeseen complications, resuscitation equip-
ment is available and, if necessary, the patient will be admitted
to a nearby hospital for further care.
The estimated total time for providing ambulatory surgical
care is approximately two to three hours.
Following are some of the typical operations that can and
have been performed at the Center:
1. Elective operations: excision of ganglion, wrist or
fingers; tenolysis (trigger fingers, de Quervain, postfrac-
ture); decompression in carpal tunnel syndrome; tendon
repair; nerve repair; open reduction of fractures, dis-
locations; repair of joint and ligament injuries; revision
of amputation stumps; correction of scar contractures;
skin grafts; excision of traumatic neuroma.
2. Emergency operations, acute injury: repair of skin
lacerations; skin graft for avulsion injuries; repair of
tendons, muscles, nerves; reduction of fractures and
dislocations; repair of joint and ligament injuries; repair
of amputations; exploration and removal of foreign
body; incision and drainage of abscess, infections.

Modus Operandi
al drapes are
The surgical gowns, patient gowns and surgic
laund ry servic e.
disposable. This eliminates
for piped-in oxygen
To avoid expensive construction costs
oxygen and nitrous oxide
and gases, the standard cylinders for
are used.
264 Kee te

The sterilization equipment consists of a compressed steam-

type unit which requires a 30-minute sterilization cycle. To
avoid unnecessary delays in resterilizing surgical equipment,
multiple sets of instruments are available for use.
In addition, power equipment — such as a power drill and a
dermatome — is available. Suction equipment available includes
a motor-driven unit and a vacuum-powered unit. For resuscita-
tion, a cardiac monitor and defibrillator are kept available at all
times, as is emergency lighting.
The preoperative laboratory examinations include deter-
mination of hemoglobin level and urinalysis. A basic charge is
made for the use of the operating and recovery rooms.
Medication and anesthetic and surgical supplies are additional
charges.
An ambulatory-surgical-care record, describing the surgical
care and anesthetic procedure, is kept for each patient.

Clinical Experience in
Ambulatory Surgical Care

From September 1972 to January 1979, 4,020 operations

were performed at the Center. Among these, there were 2,400
(60%) elective procedures and 1,620 (40%) emergency pro-
cedures. There were no anesthetic or operative complications.
For general anesthesia nonexplosive, noninflammable gases were
used. Anesthetic agents used included Pentothal Sodium,
Innovar, Sublimaze, Vistaril and Valium. For local anesthesia,
Xylocaine was used. The average duration of ambulatory
surgical care was two to three hours.
The operative procedures were classified according to three
different categories:
1. Skin lesions (21%). These included superficial lacera-
tions of the skin, avulsion loss of skin, excision of
subcutaneous lesions, scar contracture excision and skin
grafting procedures.
2. Soft tissue lesions (46%). These included injuuies and
conditions requiring excision of soft tissue masses, such
as ganglions; tenosynotivis; repair of tendons, nerves and
muscles.
 265
OUTPATIENT HAND SURGERY

of
3. Bone and joint lesions (33%). These included repair
disloca -
amputations, open reduction of fractures and
tions, and repair of joint ligament injuries.
of hospital
It is estimated that by eliminating the cost
these patient s, a savings of $500
inpatient accommodations for
d. Other advant ages are the
to $500 per patient was realize
l care for the acute injury and
availability of immediate surgica
and time loss to the patien t who
the minimum of inconvenience
undergoes an elective operation.
surgical facility
In conclusion, the concept of an ambulatory
surger y has been presented. A
specifically designed for hand
has prove d that such a concept is
six-year clinical experience
ent and more econo mical in provid-
more practical, more effici
ment for hand injuries
ing care for patients who require treat
and conditions.

Self-Evaluation Quiz
of hand operations
1. What is the approximate percentage
tient basis:
which could be performed on an outpa
a) 100%
b) 80%
c) 50%
d) 25%
e) 0%
ry surgical care center for
2. Is the concept of an ambulato
hand surgery feasible and practical?
ay) Yes
b) No
such a facility:
3. What are the advantages of
a) More efficient care
b) Less inconvenience
c) Minimum loss of time
d) More economical
e) All of the above for
of ambulatory surgical care
4. What is the average duration
hand surgery:
a) 1 to 2 hours
b) 2 to 3 hours
c) More than 3 hours
d) Less than 1 hour
266 K. L. LIE

5. Is it feasible to schedule a person who needs a major

reconstructive procedure of the hand (which will last more
than two hours) on an ambulatory basis?
a) Yes
b) No

Answers on page 527.

Bone and Joint Problems
 Displaced and Nondisplaced
Fractures in the Hand
Grady S. Clinkscales, Jr., M.D.

Objectives
1. To point out the specialized nature of fracture manage-
ment in the hand.
2. To discuss indications for internal and external fixation
of fractures.
3. To cover the specific problems with fractures at
different levels in the phalanges and metacarpals.

The principles of management in phalangeal and metacarpal

shaft fractures are the same as with fractures of the skeleton
elsewhere: reduction, stabilization and early mobilization.
Certain modifications of general fracture management, however,
bear emphasis as far as fractures in the hand and fingers are
concerned. In certain long bone fractures such as the humerus
and femur, mild angulation, rotation, even displacement and
bayonet apposition can be accepted with relative impunity. Not
so in the hand, since gliding surfaces are so closely adjacent to
periosteum. It is absolutely critical that anatomical reduction be
obtained not only as far as angulation is concerned, but rotation
as well. While x-rays can readily determine the adequacy of
overall position and alignment, it is more difficult to be
absolutely certain about correct rotational alignment. Many
times, the malrotation may appear minimal when the finger is in
an extended position, but when the finger is flexed, the rotation
magnifies and digits tend to overlap. One must watch carefully
the
on both anteroposterior and lateral projections to see that
condylar contours are in similar profile throughout the length

nt, Hand
Grady S. Clinkscales, Jr., M.D., Orthopedic Surgeon; Consulta
Surgery, Grady Memorial Hospital, Atlanta, Ga.

269
 G. S. CLINKSCALES
270

of the digit. Clinically, this can also be determined by the plane

of the fingernails when the tips of the fingers are observed end
on. Musculotendinous imbalance in a digit can occur if settling
is permitted along an oblique shaft fracture, which also must be
restored to length and held.
Stabilization may be applied externally with a small splint
or with a plaster cast for a closed, nondisplaced, stable fracture.
Stability is determined by the intactness of the surrounding
periosteum. When the periosteum is torn, as with angulated or
displaced fractures, additional stability is required, usually using
smooth Kirschner wires across the fracture site. Further
immobilization with splints, plaster cast, with or without a
Boehler attachment, is also necessary. Internal fixation using
plates and screws is usually undesirable because of the addi-
tional surgical trauma that may occur with their insertion.
Likewise, elaborate external fixators are unnecessary in the
hand because of the complexity of their application when more
simple Kirschner wire fixation is usually quite adequate.
Internal fixation is required in angulated or displaced fractures.
If the fracture is closed, percutaneous pin fixation may obviate
the necessity to open many fractures. If there is already an open
wound, internal fixation is not necessarily contraindicated,
provided that an adequate debridement of the wound can be
carried out. Whenever Kirschner wires are used, an attempt is
made to avoid transfixing adjacent joints, tendons or neuro-
vascular bundles. Postreduction roentgenograms are used as a
guide for healing, but fractures of the phalanges character-
istically show very little callus formation by the end of three
weeks. By this time, however, there is adequate healing in most
instances to permit removal of Kirschner wires. Callus forma-
tion is characteristically more noticeable at metacarpal frac-
tures, but, again, Kirschner wires can be removed and plaster
immobilization usually discontinued after approximately three
weeks, even though the fracture line is still grossly visible
radiographically.
Anesthesia for fracture reduction can be by one of several
methods. A digital block is practical if the fracture is in the
distal half of the digit. A regional block at the wrist or elbow
can also be employed. If a more extensive area of anesthesia is
necessary, then an axillary block may be used. An intravenous
HAND FRACTURES 2A A

regional anesthetic is often the most efficient way of obtaining

limb anesthesia.
Early mobilization is necessary to avoid permanent fibrosis
and stiffness about the small joint in the hand. Mobilization,
however, is partially contingent upon any concomitant soft
tissue damage, such as tendon or nerve lacerations. A careful
graduated exercise program should be employed, assisted by
dynamic splints.

Fractures at the Distal Phalanx

At the distal phalanx, most injuries involve a crushing blow

to the digit, and as such these fractures are comminuted. The
more unusual transverse fracture is usually adequately splinted
by the presence of the nail. If the nail has been avulsed with the
injury, and angulation or mobility at the fracture site is noted,
than a single longitudinally passed Kirschner wire may be used.
The angular deformity is frequently with its apex volarward,
since the blow is usually to the dorsum of the finger, forcing it
in that direction. The strong flexor profundus tendon also tends
to pull the small proximal fragment forward, accentuating this
angulation.

Fractures of the Middle and Proximal Phalanges

Fractures at the proximal two segments of the fingers and at

the proximal segment of the thumb usually angulate with the
apex in a volar direction. This is accentuated at the middle
phalanx by the strong pull of the flexor superficialis tendon,
which inserts on the base of the middle phalanx. When
displacement occurs, the distal fragment usually rides dorsally
on the proximal fragment. When angulation is minimal and one
side of the fracture hinges on an intact periosteum, with the
opposite side torn, a percutaneous transfixion of the fracture is
adequate. If the periosteum is intact on the apex side of the
fracture, while the opposite side of the cortex is impacted and
comminuted, the reduction may not remain unless internal
fixation is used. Fractures at the middle phalangeal level are
easily visualized on routine roentgenograms. Fractures at the
be
proximal phalanx are more difficult, however, and can easily
missed due to the fact that there are so many overlapping bone
DA G. S. CLINKSCALES

taken
shadows, unless additional special oblique views are also
(Fig. 1). This is particularly true of the dorsally impacte d cortex
at the base of the proximal phalanx. Such severe displacement
of these fractures can occur that the flexor tendons may
actually be displaced through the fracture site to the dorsum,
making closed reduction impossible. When internal fixation is
necessary in the transverse fracture, the Kirschner wires can be
placed in a crossed fashion to avoid passing through adjacent
joints.
A long oblique fracture tends to settle along the line of the
obliquity, distorting muscle balance. A closed reduction is
carried out, the fracture held by clamping it with a towel clip,
and percutaneous parallel Kirschner wires are driven across the
fracture site. The Kirschner wires are passed parallel to one
another, perpendicular to the long axis of the bone (Figs2).
When multiple fractures occur, Kirschner wire fixation is
particularly useful in stabilizing the skeleton. This also facili-
tates dressing changes without fear of losing reduction.

FIG. 1. Typical fracture at the base of the proximal phalanx of the ring
finger, showing impaction of the dorsal cortex and an angular deformity.
HAND FRACTURES 273

FIG. 2. Long oblique fracture of a proximal phalanx. (A) Settling along

of
the line of obliquity. (B) Postreduction film showing correct placement
in this
parallel Kirschner wires. Although four wires have been inserted
patient, usually three and sometimes only two are all that are necessary.

Fractures of the Metacarpals

At the metacarpal level fractures typically angulate with the

apex dorsally. The metacarpal normally bows in a dorsal
direction, and the interosseous muscles bow string slightly volar
the
to the long axis of the bone. Thus when a fracture occurs,
in a dorsal directio n (Fig. 3). By far the most
angulation is
shaft of
common metacarpal fracture is at the neck and distal
istically
the fifth metacarpal. An angular deformity character
reductio n is usually quite satisfact ory. A
occurs, and a closed
a short arm cast is
closed reduction will improve alignment and
little fingers. While
applied, extending to the tips of the ring and
direction from
the cast is molded, pressure is applied in a dorsal
274 G. S. CLINKSCALES

FIG. 3. Typical boxer’s fracture of the fifth metacarpal neck. (A) Typical
angular deformity. (B) Reduction and stabilization with crossed Kirschner
wires. Note that the wires do not cross the joint itself.
 275
HAND FRACTURES

the palmar side of the depressed metacarpal head, while

downward pressure is applied on the proximal portion of the
fifth metacarpal shaft. Slight residual angulation may persist or
recur, and as much as 35° of angulation can be accepted with a
good functional range of motion. Immobilization with the little
finger flexed acutely at the metacarpophalangeal and at the
proximal interphalangeal joint is strictly avoided, because this
may lead to a fixed flexion contracture, much more trouble-
some than the original injury. With severe displacement or
marked angulation, percutaneous pin fixation can be used to
secure the reduction. Rarely is open reduction necessary for this
fracture.
Oblique fractures of the central metacarpals, the third and
fourth, have less tendency to drift to a malrotated position than
the border metacarpals, the second and fifth, because of their
inherent stability through the intermetacarpal ligaments. Paral-
lel Kirschner wires are used for the oblique fracture after
restoration of proper length, and crossed Kirschner wires are
used for the transverse fracture. Immobilization in a short arm
cast with a Boehler outrigger splint will allow immobilization of
only the involved digit, while leaving all other digits free for
exercise.

Complications
on,
Complications of fracture management include infecti
an open fractur e
malunion, nonunion and _ stiffness. When
be culture d and the
becomes infected, any drainage should
ute for
appropriate antibiotics instituted. There is no substit
is involv ement of the
adequate surgical drainage, and if there
e must be more extensi ve
flexor tendon sheath, then the drainag
of the entire sheath. If the
to allow for adequate decompression
be necessary.
infection cannot be controlled, amputation may
fractu re may heal with an
In malunited fractures, the
due to overla pping, or with
angular deformity, with shortening
gnment . Derota tional oste-
a pronation or supination malali
phalan geal or metaca rpal level
otomy can be carried out at the
fixati on with Kirsch ner wires.
by a transverse osteotomy and
with a bony spike that
Angular deformities, when associated
, can be treated by removal
protrudes into adjacent soft tissues
4). If the angular deformity is
of the prominent exostosis (Fig.
276 G. S. CLINKSCALES

FIG. 4. Malunited fracture of a proximal phalanx, with a large bony spike

protruding volarward into the flexor tendon.

more than 20°, then a wedge, usually an opening wedge,

osteotomy is required to correct the angulation and restore
length. Bone grafts are used to fill the opening wedge and may
be taken from the distal radius, proximal ulna or iliac crest (Fig.
5).
Fractures may go on to a nonunion for the same reason as
in fractures elsewhere. The usual causes are inadequate im-
mobilization, loss of bone substance and infection. If infection
is present, a bone graft can be inserted once the infection has
been brought under control and remains dormant for several
weeks. In complicated nonunited metacarpal shaft fractures,
digital transposition may be an expeditious way of overcoming
defects.
Stiffness arises from two major causes: prolonged im-
mobilization and extensive soft tissue swelling which leads to
fibrosis and ankylosis of joints. Prevention is better than the
cure, and if an early exercise program can be instituted, most
problems with joint stiffness can be obviated.

Summary

The management of fractures of the phalanges and meta-

carpals is similar to fracture management elsewhere, except that
 a proximal phalanx. (A) The
FIG. 5. Malunited fracture at the base of
has healed in this positio n, creating an acute tilt of
impacted dorsal cortex
rpal. (B) An opening wedge
the joint surface at the base of the metaca
made transversely across
osteotomy at the malunited fracture site has been
crest corticocancellous bone is
the dorsal cortex. (C) A wedge of iliac
g wedge. (D, E) The healed osteotomy showing
inserted into the openin
restoration of length and alignment.
278 G. S. CLINKSCALES

anatomical reduction must be achieved for optimum results.

While closed reduction can be successfully accomplished for
most fractures, internal fixation either by percutaneous Kirsch-
ner wires or by an open reduction and internal fixation may be
required. Careful attention must be paid to restoration of
proper position, alignment and rotation. The most frequent
complications are infection, malunion, nonunion and stiffness.

Self-Evaluation Quiz

1. Percutaneous pin fixation is frequently adequate in closed

shaft fractures in the hand.
a) True
b) False
2. Rotational deformities can be accepted in the finger as in
many long bone fractures of the extremities.
a) True
b) False
3. Fractures of the middle and proximal phalanges usually
angulate apex volarward.
a) True
b) False
4. Fractures of the metacarpal shafts usually angulate apex
volarward.
a) True
b) False
5. Malrotation of metacarpal fractures is worse in the third and
fourth rays than in the second and fifth rays.
a) True
b) False
6. Serious infections may require amputation as the treatment
of choice in infected finger fractures.
a) True
b) False
7. Most nonunions are caused by inadequate immobilization,
loss of bone substance or infection.
a) True
b) False

Answers on page 527.

 Articular Fractures and Fracture
Dislocations

Joseph E. Imbriglia, M.D.

Objective

The purpose of this paper is to discuss the various types

of articular fractures and appropriate management of each,
_with emphasis on surgical techniques.

the
When treating intraarticular fractures in the hand,
stable joint with a satisfa ctory
functional goal is a painless,
d in most
range of motion. This functional goal can be achieve
ical goal of a stable, congruous
instances by gaining an anatom
in a nondis placed fractur e, thie joint
joint surface. Obviously,
ous and also most often remains stable.
surface remains congru
intraar ticular fractur es are treated by
These nondisplaced
the joint surface
immobilization for two to three weeks. When
on should be perfor med. In simple
is displaced, a reducti
finger joints, closed reducti ons are often
dislocations of the
fractures arid frac-
successful. However, in displaced articular
impossible or very
ture-dislocations, closed reductions are often
open reduction must
difficult to accomplish. In these cases, an
surface is damaged so
be performed. Occasionally, the joint
In these cases, closed
badly that it cannot be reconstructed.
treatment may be elected.
ment of intraarticular
The general indications for open treat
instability, (3) interposition
fractures are (1) irreducibility, (2)
often there is a combina-
of tissues, and (4) incongruity. Most
es open reduction. If not
tion of these problems which necessitat

Clinical Professor of Orthopedic

Joseph E. Imbriglia, M.D., Assistant
Schoo l of Medicine; Director, Hand
Surgery, University of Pittsburgh
Pittsburgh, Pa.
Clinic, Allegheny General Hospital,

279
280 J. E. IMBRIGLIA

reduced, these fractures lead to posttraumatic arthritis, resulting

in pain and decreased motion in the involved joint (Fig. 1).

Operative Technique

Most intraarticular fractures can be approached through a

dorsal curvilinear incision or a midaxial incision (Fig. 2).
Occasionally, a volar incision may be performed, as in the dorsal
fracture-dislocation of the proximal interphalangeal joint. Open
reduction of even this fracture, however, can be performed
through a midaxial approach. I prefer either the midaxial or
dorsal incision, particularly in a digit with crushed or compro-
mised skin. When using the dorsal incision over the proximal
interphalangeal or distal interphalangeal joint, the extensor
mechanism must be split longitudinally in its midline, or
retracted to either side. The insertion of the central slip or the

FIG. 1. A displaced fracture

involving the proximal-~ inter-
phalangeal joint, which was not
reduced. This has resulted in a
painful and immobile joint.
ARTICULAR FRACTURES 281

FIG. 2. (A) A midaxial incision to approach the distal interphalangeal

joint. (B) The preferred dorsal curvilinear incision over the proximal
interphalangeal joint.

distal extensor mechanism should not be surgically detached to

gain access. Over the metacarpophalangeal joint, the extensor
mechanism may be split either in the midline or through the
hood mechanism. The extensor mechanism should be repaired
following fracture fixation.
Once the fracture has been exposed, reduction is performed.
.
The reduction must generally be held with internal fixation
dependi ng on the size and
There is a variety of techniques,
wires,
location of the fragments. Small Kirschner wires, pull-out
agmenta ry screws may be used
interosseous wires or small interfr
for internal fixation.
ntly used
Kirschner wires are probably the most freque
-long, .0035 or .0045 Kirschner
device. I generally use a 4-inch
point on either end, for easy
wire. These have a trochar
nts of adequa te size, retrog rade
retrograde placement. In fragme
most efficie nt way to gain an
placement of the wire is the
In this techni que, the wire is
anatomically stable reduction.
nt surfac e until the tip of the
driven through the fracture fragme
282 J. E. IMBRIGLIA

wire is flush with the fracture surface. The fracture is then

reduced and the Kirschner wire is driven across the fracture site
to hold the reduction. The wire may be left protruding from the
skin, or it may be buried. When a fragment is judged to be too
small for a Kirschner wire, a pull-out wire may be used to secure
the fragment to the shaft. The pull-out wire technique is
particularly useful when a small fragment is attached to a
ligament. In the placement of both Kirschner and pull-out
wires, a power drill is used. The power drill actually allows less
force to be applied to a small fragment when drilling, and there
is less chance of shattering the fragment than with a hand drill.
Interfragmentary compression, using small screws, is an addi-
tional technique that is useful in selected cases. When a fracture
is securely fixed with an interfragmentary screw, motion may
be started very early (five days). The disadvantage of an
interfragmentary screw is that the screw must be removed in the
operating room under anesthesia. This technique can be used
only when the fracture fragments are large enough to hold the
screw head.

Distal Interphalangeal Joint

The most common intraarticular fracture seen at the distal

interphalangeal joint is a dorsal lip fracture, which may be
displaced or undisplaced. If displaced, the fracture results in a
mallet deformity (Fig. 3). This fracture may occur in the fingers
or in the interphalangeal joint of the thumb. If nondisplaced,
this fracture should be immobilized in extension for three
weeks. If displaced, an open reduction is usually necessary. The
fracture should be approached through a dorsal incision, and
fixation may be with either a Kirschner wire or a pull-out wire
technique. In this particular situation, I personally prefer the
pull-out wire technique.
Fractures of the volar lip of the distal phalanx are less
commonly seen. The flexor digitorum profundus tendon may
be attached to the volar lip fracture (Fig. 4), and an open
reduction of this fracture is absolutely necessary to restore
flexion to the distal interphalangeal joint. A midaxial approach
is preferable to retrieve the fragment and restore it to its normal
position. Again, fixation may be accomplished with either
Kirschner wires or pull-out wires.
ARTICULAR FRACTURES 283

i:
FIG. 3. A displaced intraarticular fracture resulting in a mallet deformity,
requires
due to a lack of extension at the distal phalanx. This fracture
open reduction.

Condylar fractures are usually the result of compressive

nt
force on one side of the joint. If nondisplaced, closed treatme
d, closed reducti on
with immobilization is adequate. If displace
and will
may be attempted. However, the fractures are unstable
fixation (Fig. 5).
generally displace if not held with internal
at the distal inter-
Adequate exposure for condylar fractures
can be
phalangeal joint and the proximal interphalangeal joint
extenso r mechani sm
obtained through a midaxial approach. The
ligamen t may have to
is retracted dorsally. Part of the collateral
to gain adequat e
be removed from the condylar fragment
t is secured to
visualization of the joint. The fracture fragmen
screws may be
the shaft as tightly as possible. Interfragmentary
FIG. 4. The flexor digitorum profundus tendon is attached to the fracture
fragment. The fragment is rotated 180° and requires open reduction.
(Reproduced with permission from the book Atlas of Wrist and Hand
Fractures by Sigurd C. Sandszén, Jr. © 1979 by PSG Publishing Cosine?
Littleton, Mass., U.S.A.)

FIG. 5. A displaced condylar

fracture in the distal interphalan-
geal joint.
ARTICULAR FRACTURES 285

Sess
os

FIG. 6. Angular deformity at the PIP joint following a displaced condylar

fracture.

useful in this particular type of fracture, if the fragment is large

enough. An untreated displaced condylar fracture may result in
an angular deformity of the joint, in addition to pain and
decreased range of motion (Fig. 6).

Proximal Interphalangeal Joint

Volar lip fracture of the middle phalanx with dislocation of

the middle phalanx dorsally is one of the more difficult
fractures in which to restore normal motion without pain [1].
The volar fracture fragment is attached to the volar plate,
leaving the middle phalanx without any stabilizing structure on
its volar aspect (Fig. 7). In this situation, it is absolutely
necessary to reduce the dislocation and restore joint congruity.
splint,
This may be done by closed reduction with an extension
and O’Brien [2]> If the
as described by McElfresh, Dobyns
the reduction, then open
extension splint does not hold
has described a technique
reduction must be performed. Eaton
defect of the
in which the voiar plate is advanced into the bone
(Fig. 8) [1]. The results
middle phalanx and secured in position
 J. E. IMBRIGLIA
286

FIG. 7. A fracture-dislocation of the middle phalanx, requiring reduction

of the dislocation and restoration of the joint surface.

of the procedure are quite good, as long as an absolutely

accurate reduction of the dislocation is accomplished. I have
not been as successful as Dobyns in holding the reduction with
an extension block splint. Most often, I have had to open these
fractures. Even in chronic cases of this fracture-dislocation,
open reduction may be successful in relieving pain and restoring
joint motion (Fig. 9). Following open reduction, motion is
begun on the 14th postoperative day. The internal fixation is
left in place for 21 days.
A fracture of the dosral lip of the middle phalanx with
displacement may result in a boutonniere deformity of the
proximal interphalangeal joint. In this fracture, the central slip
is attached to the fragment. If displaced, open reduction and
reattachment of the fragment is necessary. At surgery, repair of
the central slip to the lateral bands may also be necessary, if the
central slip and fracture fragments have displaced proximally.
The incidence of this fracture, when compared with volar lip
fractures, is quite low.
As in the distal interphalangeal joints, condylar fractures of
the proximal phalanx must generally be internally fixed after
ARTICULAR FRACTURES 287

FIG. 8. The pull-out wire technique for stabilization of fracture-disloca-

tions in the proximal interphalangeal joint.

re-dislocation of the proximal

FIG. 9. (A) Four months following a fractu
there was persis tent sublux ation, resulting in pain, and a
phalangeal joint,
open reduct ion, the patient regained 90°
20° are of motion. (B) Following
of painless motion.
288 J. E. IMBRIGLIA

FIG. 10. A displaced unstable fracture, treated by open reduction and

interfragmentary screw compression.

reduction. Interfragmentary screws have been most useful in

stabilizing this fracture (Fig. 10).
When the entire joint surface of the proximal phalanx is
displaced dorsally, there is a complete block to flexion. In this
situation, a dorsal or midaxial approach is used, and the
articular surface is reduced on the proximal phalanx and held
with an intramedullary wire. I have been most successful in
driving a small Kirschner wire through the condylar fragment
and through the proximal interphalangeal joint. I then reduce
the articular fracture on the proximal phalanx, and run the wire
from distal to proximal across the fracture site (Fig. 11). The
wire is removed three weeks postoperatively.

Metacarpophalangeal Joint

At the metacarpophalangeal joint level, avulsion fractures

occur at the ligament attachment to the proximal phalanx. This
is most commonly seen in the thumb metacarpophalangeal
joint. The ulnar collateral ligament avulses the fragment off the
ARTICULAR FRACTURES 289

in an
FIG. 11. (A) A six-week-old fracture of the proximal phalanx
surface of the proximal phalanx is
8-year-old boy. The entire articular
dorsally, and there is a complete block to extension. (B) An
displaced
held with an
open reduction was performed, the fracture reduced and
llary Kirschner wire. Immobiliz ation continued for three weeks,
intramedu
following which the patient regained joint flexion.
290 J. E. IMBRIGLIA

FIG. 12. A gamekeeper’s thumb,

which is unstable when stressed.

proximal phalanx (gamekeeper’s thumb) (Fig. 12). The frag-

ment often rotates 90° to 180°, and may result in a nonunion if
not properly reduced (Fig. 13A). In addition to the ununited
fragment, there is a chronic instability due to ligamentous
laxity. If there is ligamentous laxity, combined with a displaced
avulsed fragment, the joint should be opened, the fragment
reduced and the soft tissues repaired (Fig. 13B). The operation
can easily be performed through an ulnar incision. The adductor
apponeurosis is split for adequate visualization of the ligament
and fracture fragment.
Direct injury to the proximal portion of the metacarpal
head may result in articular surface displacement. Reduction is
performed, based on the amount of displacement and the
feasibility of reconstructing the fragments (Figs. 14 and 15).
Fracture-dislocations at the base of the thumb (Bennett
fracture) may be treated by closed reduction and casting, closed
reduction and percutaneous pin fixation, or open reduction and
internal fixation. In an acute Bennett fracture, the closed
reduction is usually quite simple. With the patient under
anesthesia, traction is applied to the thumb, while direct
pressure is applied on the proximal metacarpal, which is
 B
attached to the ulnar collateral
FIG. 13. (A) A displaced fracture which is
on the metaca rpopha langea l joint. (B) Reduction of the displaced
ligament
articular fragment.

of the proximal
ving intraarticular surface
FIG. 14. A fracture invol n was perf ormed through a
An open redu ctio
phalanx with subluxation. d and held with a
ments were reconstructe
dorsal approach. The frag
Kirschner wire.
FIG. 15. (A) A displaced fracture of the metacarpal head. (B) Restoration
of articular surface congruity in the metacarpal head. The procedure was
performed through a dorsal approach, splitting the extensor mechanism.
The Kirschner wires have been removed.

FIG. 16. A displaced Bennett fracture reduced by closed reduction and

percutaneous pin fixation.
ARTICULAR FRACTURES 293

brought into an abducted and extended position. Once reduced,

the fracture-dislocation is unstable because of the proximal pull
of abductor pollicis longus combined with the force of the
adductor pollicis. A percutaneous pin may be inserted across
the base of the metacarpal to stabilize the dislocation (Fig. 16).
A thumb spica cast can then be applied over the reduced
metacarpal, with the Kirschner wire in place. If closed reduction
is unsuccessful, an open reduction should be done.

Immobilization

im-
Intraarticular phalangeal fractures should generally be
mobilized for 21 days. The Kirschn er wires holding the fracture
may
fragments may also be removed at 21 days. Earlier motion
cases where the fixation is very rigid,
be started in those special
may be
as with the A-O small fragment screws. Immobilization
where there is concom itant injury (e.g. a
longer in those cases
ty. Bennett fracture s are immobil ized for
boutonniére deformi
five weeks.
Kirschner
Following plaster removal and removal of the
m should be initiat ed, consis ting of both
wire, a therapy progra
of motion exercis es. Dynam ic tractio n
active and passive range
, particularly in
and splinting may be necessary to regain motion
es of the proxim al interp halang eal joint.
the displaced fractur

References

Springfield:Charles C Thomas,
1. Eaton, R.G.: Joint Injuries in the Hand.
ibe)
O’Brien, E.T.: Management of
2. McElfresh, E.C., Dobyns, J.H. and
of the proxi mal interp halangeal joints by extension
fracture dislocation
705-1 711, 1972.
block splinting. J. Bone Joint Surg. 54A:1

Self-Evaluation Quiz
s usually require open
1. Dislocations of the finger joint
reductions.
a) True
b) False
can be employed in most
2. A dorsal or midaxial incision fracture-
fractures, exce pt the dorsal
intraarticular
a volar incision.
disclocation, which always requires
294 J. E. IMBRIGLIA

a) True
b) False
3. Which method of internal fixation is most useful when a
small fragment is attached to a ligament?
a) Kirschner wire
b) Interosseous wire
c) Pull-out wire
d) Interfragmentary screw
4. Motion may be started as early as five days with use of:
a) Kirschner wire
b) Interosseous wire
c) Pull-out wire
d) Interfragmentary screw
5. Fractures of the volar lip of the distal phalanx are less
common than of the dorsal lip.
a) True
b) False
6. Interfragmentary screws are especially useful in condylar
fractures.
a) True
b) False
7. Fracture of the dorsal lip of the middle phalanx with
displacement may result in:
a) Mallet deformity
b) Angular deformity
c) Boutonniere deformity
d) None of the above
8. Metacarpophalangeal joint avulsion fractures occur most
often in:
a) Index finger
b) Long finger
c) Little finger
d) Thumb
9. A Bennett fracture is a fracture-dislocation of the meta-
carpal head.
a) True
b) False

Answers on page 527.

 Dislocations of the Small
Joints of the Hands —
Simple and Complex
David C. Bush, M.D.

Objectives

{. To discuss the anatomy of the small joints of the hand

of
and the relevance of this anatomy to dislocations
those joints.
disloca-
2. To define and discuss the treatment of simple
tions of the small joints of the hand.
complex
3. To define and discuss the treatment of
dislocation of the small joints of the hands.

Introduction

hand are among the

Dislocations of the small joints of the
they get treated on
most common injuries to the hand. Often
er playe r, and many do
the playing field by a trainer or anoth
when they are improperly
well. However, some of these injuries,
ility and pain. Most of the
treated, can lead to chronic instab
proxi mal inter phalangeal
dislocations of the hand occur at the (MP) joint
arpop halan geal
(PIP) joints of the finger and metac
that dislo catio ns cannot
of the thumb. It should be emphasized the major
of one or more of
occur without complete rupture failur e to
a joint, and the
supporting structures around to futur e
are injur ed can lead
recognize the structures that stics of the
review the chara cteri
disability [1-4]. This paper will
of the MP joints and IP joints of the fingers and the
dislocations
hand, both simple and complex.

Geisinger Medical
M.D., Associate in Orthopaedics,
David C. Bush,
Center, Danville, Pa.

295
296 D. C. BUSH

The Proximal Interphalangeal Joint

The proximal interphalangeal joint is essentially a hinge

joint with motion mainly in the flexion and extension plane. It
differs from the MP joint in that its collateral ligaments are tight
throughout its plane of motion, and that its tight volar plate
does not permit hyperextension. This also is a bicondylar joint
in comparison with the unicondylar nature of the metacarpo-
phalangeal joint (Fig. 1) [5, 6].
Posterior or dorsal dislocations of the proximal inter-
phalangeal joint are the most common form. In this injury, the
patient is usually struck on the end of the finger and sustains a
hyperextension force at the proximal interphalangeal joint. The
force is directed mainly to the proximal interphalangeal joint
because of the longer lever arm of force at this level, compared
to the distal interphalangeal joint, and the relative immobility

MP Joint IP Joint
FIG. 1. The metacarpophalangeal joint is unicondylar in comparison with
the proximal interphalangeal joint, which is bicondylar.
SMALL JOINT DISLOCATIONS 297

of the proximal interphalangeal joint in the extension plane,

compared to the metacarpophalangeal joint.
The clinical diagnosis is usually obvious because of the
dorsal deformity produced by the base of the proximal phalanx.
In a true dorsal dislocation, the collateral ligaments remain
intact but there is a tear of the volar plate from its distal
attachment at the base of the middle phalanx. This is in
contrast to the MP joint dislocation where the tear is usually
proximal. The tear extends through the accessory collateral
ligament (Fig. 2) [7].
Treatment consists of closed reduction by hyperextending
the distal segment and pushing the middle phalanx into a
reduced position. Early motion is advocated because the
problem at this joint is stiffness and loss of motion rather than
instability. I prefer to immobilize the joint completely for
several days to allow the swelling to subside and then begin
of
early motion in the flexion plane with a block to the last 30°
here is to allow the volar
extension [8]. The important concept
laxity
plate to heal to avoid the late complication of volar plate
flexion. Flexion splinting is
in the patient with a double arc of
weeks, and then the fingers are
carried out for a total of three
It should be
protected by buddy taping for three more weeks.
swelling with this injury may
noted that pain, stiffness and
persist for up to six months.
eal joint is
Anterior dislocation of the proximal interphalang
[9]. The proble m here is
rare but very important to recognize
ated with ruptur e of the
that this dislocation is frequently associ

Collateral Ligament

Accessory ~~
Collateral
Ligament
Volar Plate
of the PIP joint.
FIG. 2. Simple dorsal dislocation
298 D. C. BUSH

central slip of the extensor tendon. The anatomic problem is

similar to that of acute boutonniére deformity, and although
some authors recommend operative repair of the central slip, I
prefer treatment with a splint and full extension for a period of
five weeks. The splint may be applied to allow motion at both
the MP and DIP joints.
Radial or ulnar dislocations are less common than the dorsal
dislocations because of the relative strength of the collateral
ligaments, compared to the volar plate. The important path-
ology to recognize here is a tear of the collateral ligament
system. Frequently the volar plate may be torn also. Some
authors advocate operative repair of acute complete collateral
ligament injuries [10, 11]. Again, the problem of this joint is
usually stiffness rather than instability. Chronic instability of
the collateral ligaments of this joint has not been a problem in
my hands, and I prefer splinting for three weeks in 30° of
flexion, followed by protected motion (Fig. 3).

Metacarpophalangeal Joint

Dislocations of the metacarpophalangeal joint of the thumb

are second in number only to the dislocations of the proximal
interphalangeal joints of the fingers, and are probably more
important in terms of total function of the hand. The
metacarpophalangeal joint allows motion in two planes when
compared to the proximal interphalangeal joint. It is a
unicondylar joint. The collateral ligaments are relatively loose in
extension and tightest in flexion. Also, as opposed to the
proximal interphalangeal joint, hyperextension of the meta-
carpophalangeal joint, either of the fingers or of the thumb, is
possible. Because of the relative mobility of this joint, simple
dorsal dislocations are uncommon. When they occur without
collateral ligament injury, they can usually be treated in flexion
in a thumb spica to allow volar plate healing. I usually
immobilize these dislocations for a total of six weeks, because
in these instances, stability is more important than mobility.
Most dislocations of the MP joint of the thumb result in a
tear of either the radial collateral ligament or, more commonly,
the ulnar or web collateral ligament. Because of the importance
of stability in this joint, after a thumb metacarpophalangeal
joint dislocation is reduced, stress films should be obtained with
SMALL JOINT DISLOCATIONS 299

and
FIG. 3. Ulnar dislocation of the PIP joint treated by closed reduction
splinting.

ts is
adequate anesthesia if a tear of the collateral ligamen
ve repair
suspected (Fig. 4) [12]. If the joint is unstable, operati
consid ered [13]. As Stenner has shown, a ruptured
should be
aspect,
collateral ligament of the thumb, especially on its ulnar
[14]. If this is
can get caught outside the extensor mechanism
positio n and
the case, the ligament will not heal in an anatomic
joint is unstabl e, I
chronic instability will be the result. If the
treatme nt is often
prefer operative repair because closed
unsuccessful [15].
are similar in
Metacarpophalangeal dislocations of the finger
geal disloc ations of
terms of anatomy to the metacarpophalan
disloc ation is more
the thumb [16]. In these joints, dorsal
ation becau se of the
common than radial or ulnar disloc
adjac ent digits. Treat ment
protection to stresses afforded by the
means . I prefer treat ment
is usually satisfactory by closed
joints , that is, protec tive
similar to treatment for the PIP
n plane.
splinting and early motion in the flexio
300 D. C. BUSH

FIG. 4. Unstable thumb MP joint shown by stress tray with local

anesthesia.

Distal Interphalangeal Joints

Dislocations of the distal interphalangeal joints of the

fingers or of the interphalangeal joint of the thumb are unusual
because of the relatively shorter lever arm and, therefore, the
reduced force of this level. Closed reduction is usually possible,
although it may be difficult to hold a reduction in a cast. If this
is the case, percutaneous fixation with a Kirschner wire may be
a more satisfactory means of treatment. The collateral ligaments
usually heal without difficulty. The most important thing to
remember in the treatment of these injuries is to be sure that an
avulsion of either the flexor or extensor tendon is not missed.

Complex Dislocations

Complex dislocations are irreducible dislocations. They are

most common in the hand at the MP joint level of the fingers,
though they have also been reported at other levels. As
McLaughlin pointed out in his article on complex dislocation,
Malgaigne, in 1855, was probably the first to describe a
complex dislocation [17]. Other early descriptions and reviews
of this condition include those by Farabeuf [18], Polail-
SMALL JOINT DISLOCATIONS 301

lon [19] and Le Clerc [20]. Kaplan’s classic article describes

the pathological anatomy of this injury in great detail [21].
More recently, Green has also reviewed the problem and its
anatomy [22].
Usually the dislocation appears dorsally at the metacarpo-
phalangeal joint. Rather than a disruption of the volar plate
distally, as in the usual case, with a proximal interphalangeal
dislocation, the disruption is proximal at the site of the weak
attachment to the volar plate to the metacarpal neck. The volar
plate then becomes trapped between the base of the proximal
phalanx and the metacarpal head, preventing a concentric
reduction (Fig. 5). The other factors in the complex dislocation
have been nicely reviewed by Kaplan [21]. Usually the meta-
carpal head becomes buttonholed through the structures vo-
larly. The flexor tendon wraps around the metacarpal head on
its radial side, and the lumbrical and neurovascular bundle on
the ulnar side. The superficial transverse metacarpal ligament
traps the metacarpal head proximally, and the natatory liga-
ments trap it distally. A simple dislocation can easily be
converted into a complex dislocation by using traction as the
only reduction maneuver, rather than a hyperextension force.
Although some authors have used a dorsal approach, the best
operative approach to these complex dislocations is volarly.
Thorough knowledge of the normal and pathological anatomy is
necessary prior to approaching one of these dislocations. Care
must be taken to avoid the prominent neurovascular bundles

Volar Plate torn volar plate

FIG. 5. A complex dislocation with the proximally
interposed in the joint.
 D. C. BUSH
302

which frequently lie over the metacarpal head in a very

superficial fashion. Following open reduction, early motion can
be begun with protective splinting, depending on the stability of
the joint following the reduction. If the joint is unstable,
temporary Kirschner wire immobilization may be indicated.
Complex dislocations can also occur at other joints of the
hand but they are unusual [23, 24]. They have been reported at
the proximal interphalangeal joint and at the distal inter-
phalangeal joint. Again, the main problem appears to be
entrapment of the volar plate in the joint. In contrast to the
normal or simple dislocations where the tear in the volar plate is
distal, the volar plate tear in these complex interphalangeal
dislocations is proximal. As with the MP joint, a knowledge of
the pathologic anatomy is required before these complex
interphalangeal dislocations can be treated.

References

1. Kaplan, E.B.: Functional and Surgical Anatomy of the Hand, ed. 2.

Philadelphia:J. B. Lippincott Co., 1965.
2. Moberg, E.: Fractures and ligmentous injuries of the thumb and
fingers. Surg. Clin. North Am. 40 (2):297-309, 1960.
3. Green, D.P. and Rowland, S.A.: Fractures and Dislocations in the
Hand. Rockwood and Green Fractures. Philadelphia:J. B. Lippincott
Co., 1965, p. 265.
4. Milford, L.: Campbell’s Operative Orthopaedics. The Hand. St.
Louis:C. V. Mosby Co., 1971, p. 183.
5. Kuczynski, K.: Less-known aspects of the proximal interphalangeal
joints of the human hand. Hand 7 (1):31-33, 1975.
6. Kuezynski, K.: The proximal interphalangeal joint anatomy and
causes of stiffness in the fingers. J. Bone Joint Surg. 50B:656-663,
1968.
7. Brunelli, G., Morelli, E. and Salvi, V.: Traumatic lesions of tendons
and ligaments of the proximal interphalangeal joint. Hand 7
(1):48-45, 1975.
8. McElfnesh, E., Dobyns, J.H. and O’Brien, E.T.: Management of
fracture dislocation of the proximal interphalangeal joints by exten-
sion block spinters. J. Bone Joint Surg. 54A:1705-1711, 1972.
9. Spinner, M. and Choi, B.Y.: Anterior dislocation of the proximal
interphalangeal joint. J. Bone Joint Surg. 52A (7):1329-1336, 1970.
10. Reddler, Z. and Williams, J.T.: Rupture of a collateral ligament of the
proximal interphalangeal joint of the fingers. J. Bone Joint Surg. 49A
(2):322-326) 1967.
11. McCue, F.C., Honner, R., Johnson, M.C. and Gieck, J.H.: Athletic
injuries of the proximal interphalangeal joint requiring surgical
treatment. J. Bone Joint Surg. 52A (5):937-967, 1970.
SMALL JOINT DISLOCATIONS 303

12. Palmer, A.K. and Louis, D.S.: Assessing ulnar instability of the
metacarpophalangeal joint of the thumb. J. Hand Surg. 3 (6):542-546,
1978.
13. McCue, F.C., Hakala, M.W., Andrews, J.R. and Gieck, J.H.: Ulnar
collateral ligament injuries of the thumb in athletes. J. Sports Med. 2
(2):70-81, 1974.
14. Stenner, B.: Displacement of the ruptured ulnar collateral ligament of
the metacarpophalangeal joint of the thumb. J. Bone Joint Surg. 44B
(4):869-879, 1952.
15. Bowers, W.H. and Hurst, L.C.: Gamekeepers thumb evaluation by
arteriography and stress roentgenography. J. Bone Joint Surg.
59A:519-524, 1977.
16. Baldwin, L.W., Miller, D.C., Lockhart, L.D. and Evans, E.B.:
Metacarpophalangeal joint dislocations of the fingers. J. Bone Joint
Surg. 49A (8):1587-1590, 1967.
ale McLaughlin, H.L.: Complex “‘locked”’ dislocation of the metacarpo-
phalangeal joints. J. Trauma 5 (6):683-686, 1965.
18. Farabeuf, L.H.F.: De la luxation du ponce en arriere. Bull. Soc. Int.
Chirata2k. la7G.
NS). Polaillon, J.F.B.: Dict. Encyclopedique Sc. Med., Art. Doigt. Cited by
Le Clerc, R.: Luxations de le index sur son metacarpien. Rev. Orthop.
DO 27-2425 09 ide
20. Le Clerc, R.: Luxations de le index sur son metacarpien. Rev. Orthop.
De? 2A De Ae
of
21. Kaplan, E.B.: Dorsal dislocation of the metacarpophalangeal joint
the index finger. J. Bone Joint Surg. 39A (5):1081-1086, 1957.
-
22. Green, D.P. and Terry, G.C.: Complex dislocations of the metacarpo
phalangeal joint. J. Bone Joint Surg. 55A (7):1480-1486, 1973.
proximal inter-
23. Murakami, Y.: Irreducible volar dislocation of the
phalangeal joint of the finger. Hand,vol. 6, no. 1, 1974.
of the distal
24. Palmer, A.K. and Linsheid, R.L.: Irreducible dislocation
408, 1977.
interphalangeal joint of the finger. J. Hand Surg. 2 (5):406-

Self-Evaluation Quiz
tear in the volar
In a simple dislocation of the PIP joint, the
plate is usually proximal.
a) True
b) False
The MP joint is a unicondylar joint.
a) True
b) False
A complex dislocation is:
teral ligaments
a) A dislocation with a tear of the colla
rupt ure of the flexor or extensor
b) A dislocation with
tendons
304 D.C. BUSH

c) An irreducible dislocation
d) An open dislocation
4. Complex dislocations are most common at:
a) The PIP joint
b) The DIP joint
c) The carpometacarpal joint
d) The MP joint

Answers on page 527.

 Capsular Injuries of the Proximal
Interphalangeal Joint
William H. Bowers, M.D.

Objective

The frequency of small-joint capsular injuries demands

an understanding of pathoanatomy in order to avoid serious
drifts into over- or under-treatment patterns. This paper
emphasizes the close relationship between anatomy and
function in these small joints and supplies a method of
diagnosis that will lead to correct management.

ely
Capsular injuries of the small hand joints are extrem
injuries usually
common and comprise a great portion of those
paper
termed a “jammed finger” or a “‘chip fracture.’’ This
tries to commun icate
departs from an all-inclusive approach and
of any
via a single injury spectrum the important aspects
joint is the proxim al
capsular injury. Chosen as the illustrative
Curtis has called the
interphalangeal (PIP) joint, which Ray
any other,
“epicenter” of hand surgery. This joint, more than
convers ely, if motion and
restricts hand function if stiff;
even in the face of other
stability remain at this joint —
be preserved.
small-joint damage — good hand function can
any injury is anatomy. The
The basis of understanding
joint is bicon dylar (Fig. 1) and the
osseous conformation at this
The middl e phala ngeal articular
condyles are flared volarly.
le, and a volar tuberc le covered
surface is cupped for each condy
the volar plate menis cus — a
with articular cartilage faces
at this
mechanism allowing a 120° to 130° range of motion

Section, Division of Orthopedic

William H. Bowers, M.D., Chief, Hand
North Caroli na Schoo l of Medicine, Chapel Hill.
Surgery, University of

305
306 W. H. BOWERS

FIG. 1. Volar exposure of the PIP joint demonstrating the bicondylar

nature of the joint surfaces with the volar flares obvious. The articular
coverage of the volar tubercle of the middle phalanx is well demonstrated.
The volar plate is split centrally and turned laterally. The thin central
portion can be noted at the distal margin.

joint (Figs. 2 and 3). The proper collateral ligament originates in

a concavity on the dorsolateral aspect of the condyles and
inserts on the volar lateral aspect of the middle phalanx in
conjunction with the volar plate. Proper collateral ligaments are
tighter in flexion as they rotate over the lateral flare of the
condyles. However, they offer significant stability to lateral
stress in all ranges. The volar capsule is anatomically distinct
and called the volar plate. It originates proximally on the lateral
ridge of the proximal phalanx where the A2 pulley ends via two
strong attachments resembling a swallow’s tail (Fig. 4). The arch
of the ‘‘twin tails’’ embraces the vascular supply to the flexors
(Fig. 5). The volar plate’s distal attachment is again strongest
laterally, where it is confluent with the inferior fibers of the
proper collateral ligament. These strong, predominantly lateral
struts are loose in flexion but taut in extension, providing the
major resistance to hyperextension stress. The central portion
of the distal insertion is relatively thin and weak. It is primarily
CAPSULAR INJURIES/PIP JOINT 307

PROPER COLEEATERAL
LIGAMENT
CENTRAL SLIP

ACCESSORY
COLLATERAL
LIGAMENT

PROXIMAL =
LATERAL REIN ~
MIDDLE PHALANGEAL
RECESS ATTACHMENT OF CENTRAL
80% OF VOLAR PLATE

INTRAARTICULAR VIEW
s HEMI SECTION OF VOLAR PLATE
FIG. 2. (Reprinted from Bowers et al [1].)

in extension and flexion, demon-

FIG. 3. Proximal interphalangeal joint
of the volar plate and flexor sheath mechanism.
strating the mobility
(Reprinted from Bowers et al [1].)
308 W. H. BOWERS

FIG. 4. The swallow tail configuration of the proximal end of the volar
plate is well seen. The cruciate 1 (C1) pully is divided in its central portion
and reflected laterally in the clamps. (Reprinted from Bowers et al [1].)

an extension of volar plate fibers into the periosteum of the

volar middle phalangeal metaphysis — not into the volar
tubercle which is covered with articular cartilage. Thus the
volar-plate strength is lateral both proximally and distally. The
capsular connection between the proper collateral ligament and
the volar plate is called the accessory collateral ligament. It is
relatively thin and acts more as a suspensory ligament for the
volar plate. The accessory collateral ligament and lateral margins
of the volar plate tighten when full extension is reached and are
stretched taut by the lateral flare of the condyle, providing
significant resistance to lateral stress in this position.
Because of the intricate anatomy, small degrees of swelling
will produce a significant decrease in range of motion — hence
the relatively long time for proximal interphalangeal joints to
recover full motion after a significant injury.
We will consider as a type injury a “‘pure”’ injury of the
volar capsule — hyperextension. This is a common problem
clinically, and worthy of attention. As hyperextension stress
increases, tension develops within the volar plate and the
CAPSULAR INJURIES/PIP JOINT 309

VINCULAR
FEEDER

OBLIQUE VOLAR VIEW

VOLAR PLATE AND RELATIONS
FIG. 5. (Reprinted from Bowers et al [1].)

accessory collateral ligament. The resultant injury pattern

depends very much on the rapidity with which the stress is
applied. If applied slowly, the proximal attachments, or
“swallow tails,” attentuate and ultimately fail. The joint may
sublux dorsally, even dislocate, pulling the intact volar plate and
like a
accessory collateral ligament complex over the condyles
of tension is a clinical rarity.
shroud. This slow application
rapidly
Much more often the force is applied rapidly. With the
ligament fails — centrally first —
applied stress the distal
a piece of the volar metaphysi s, but just as
occasionally avulsing
the menis-
often the thin central volar plate corresponding to
ruptured without a bony fragment (Fig. 6).
coid portion will be
, the lateral struts of the volar plate fail.
If the stress continues
intact, rupture
These struts, which up to this point have been
extends proximall y between the accessory col-
and the rent
The middle
lateral ligament and proper collateral ligament.
hinging on the proper
phalanx may then (Fig. 7) swing dorsally,
stress in its lower
collateral ligament origins and developing
without disruption
fibers. The joint may completely dislocate
310 W. H. BOWERS

EXPERIMENT NUMBER 6

FIG. 6. (Reprinted from Bowers et al [1].)

of the proper collateral ligament if the force remains “pure”

hyperextension.
A usual injury story begins as the patient arrives with a
history of a rapidly applied force, stressing his finger in
hyperextension. His true lateral x-ray film may be negative,
show a small fleck of bone volarly at the PIP joint or show a
dislocation, with or without fleck of bone. It is essential to
recognize that either of the first two may represent the same
degree of injury as the dislocation. To arrive at an accurate
diagnosis, we note that the maximum tenderness is volarly
specifically at the joint level. At this point, we may presume a
volar plate injury and must now assess volar stability by
stressing the joint and comparing it with adjacent or opposite
digits. For this, a metacarpal block is used. The patient is then
asked to perform a full range of motion. If the joint subluxes or
dislocates within this active range of motion, then obviously
stability is lost. It is important, however, to stress the joint
manually, as not all completely ruptured volar capsules will
CAPSULAR INJURIES/PIP JOINT aula

allow subluxation on voluntary ranging. The patient with the

“chip” fracture may be stable laterally and volarly, but this
should not be surprising. This patient has avulsed the central
portion of the volar plate, but the force has not disrupted the
critical lateral volar plate attachments (Fig. 5). This injury is
common and commonly overtreated. It requires only buddy-
system taping for a week or so and will invariably heal without
problems. The early motion is essential to reduced morbidity.
Both the patient with a ‘‘chip”’ fracture and the patient with
a negative x-ray film may, however, demonstrate complete loss
of volar stability with hyperextension stress. Here, the presence
of a chip fracture is of prognostic significance. If the avulsion
fracture is present, the patient is usually recognized as having a
legitimate injury. Whether or not the loss of volar stability is
recognized, the digit will probably be splinted. The avulsed
metaphyseal fragment will heal bone-to-bone in two to three
weeks. If the volar instability is recognized, one will apply a
dorsal blocking splint, preventing full extension but allowing
flexion, for three weeks. Such a patient will heal without
significant morbidity.
The injury usually unrecognized is the volar plate injury
with loss of volar stability and no fracture visible on x-ray film.
The diagnosis is usually “‘sprain” and no splint may be applied.
of
This patient requires dorsal block splinting. Splinting here is
than in the first patient, for the injury is
more importance
avascular fibrocart ilage with a poor blood
through relatively
splinting
supply to the healing surfaces (Fig. 8). Healing without
injury is much like a central slip rupture dorsal
is unlikely. This
Eventuall y, the condyles buttonho le through
to this same joint.
a chronic
the volar capsule and the patient will develop
deformit y (Fig. 9) — a “reverse boutonni ére”’ at
hyperextension
trouble
the proximal interphalangeal joint. Even at this point,
mallet finger.
looms, because the digit may resemble a chronic
single him out
Thus, we must correctly identify this patient and
avoid late problems .
as one for whom treatment is essential to
this, the “epi-
The type of capsular injury presented at
rum of injury from
center” of hand surgery, represents a spect
der capsular injuries
inconsequential to disabling. We must consi
and overtreating the
as such or discover ourselves both ignoring
same injury.
BLY W. H. BOWERS

FIG. 8. Vascular injection study by James Hunter, M.D., Philadelphia,

demonstrating the avascular distal portion of the proximal interphalangeal
joint volar plate (arrow).

FIG. 9. The chronic hyperextension deformity resulting from a volar plate

injury. The resemblance to a chronic mallet finger should be noted.
CAPSULAR INJURIES/PIP JOINT ole

Reference

1. Bowers, W.H., Wolf, J.W., Jr., Nehil, J.L. and Bittinger, S.: The
proximal interphalangeal joint volar plate. I. An anatomical and
biomechanical study. J. Hand Surg. 5:79-88, 1980.

Self-Evaluation Quiz

1. In a multijoint injury of the hand, resultant functional

ability is directly related to recovery of motion and stability
at the
a) Metacarpophalangeal joint
b) Proximal interphalangeal joint
c) Distal interphalangeal joint
2. The proximal origin of the volar plate is:
a) Midline by a single strong band
b) By twin “‘tails” at the distal margin of the A2 pulley
c) Via Sharpey’s fibers near the A4 pulley
3. Hyperextension injuries produce volar capsular tears — the
site depending on:
a) Rate of force application
b) Joint position at the time of injury
c) Magnitude of force applied
e
4. A dorsal dislocation is always associated with complet
disruption of at least one collater al ligament .
ah bruce
b) False
fragment
5. Volar capsular injuries with avulsion of a bone
usually imply volar instabi lity.
a) True
b) False
volar capsular
6. The significance of an avulsion fracture in
injuries is:
splint
a) That fracture recognition will usually stimulate
treatment which is adequate
b) Usually an indication for open reduction
c) None
treated by:
7. Most volar capsular injuries are adequately
a) Splinting the joint in full extension
allowing flexion
b) Asplint blocking full extension but
c) A transarticular K wire
d) Immediate “buddy”’ taping
314 W. H. BOWERS

8. The complete volar capsular disruption with no avulsion

fracture is often missed; it may be best diagnosed with the
aid of:
a) Arthrography
b) Metacarpal block with hyperextension comparison
stressing of joint
c) A true-lateral x-ray

Answers on page 527.

 Arthritis of the Basal Thumb
Joints: A Technique for
Implant Arthroplasty
James W. Strickland, M.D.

Objectives
1* To identify the incidence, clinical presentation and
radiographic findings in arthritis of the basal thumb
joint.
2. To discuss the reconstructive requirements of any
procedure designed to relieve pain at the basal thumb
joint.
3. To list the surgical options available, with consideration
of the advantages and disadvantages of each.
4. To discuss in detail an interpositional arthroplasty
utilizing the silicone rubber implant (Swanson) and a
personal technique of the author.
5. To consider the possible complications of this pro-
cedure and the methods for salvaging a failure.

Arthritis of the joint at the base of the thumb is an

most
extremely frequent and disabling condition which occurs
middle- age group. This conditi on is
often in women in the
degener ative arthritis (osteoar thritis) ,
commonly secondary to
such
although rheumatoid arthritis and posttraumatic arthritis
g a Bennett fracture may also be
as that found followin
been shown that the dominan t hand
precipitating entities. It has
hand; yet
is somewhat more affected than the nondominant
in at least 25% of the cases.
bilateral involvement occurs
Associate Professor of
James W. Strickland, M.D., F.A.C.S., Clinical
Univers ity Medical School; Chief, Hand
Orthopaedic Surgery, Indiana
ns, Indiana Univers ity Medical Center; Chief, Section of
Surgery Rotatio
Orthopa edic Surgery , St. Vincent Hospital,
Hand Surgery, Department of
Indianapolis, Ind.

315
316 J. W. STRICKLAND

This clinical entity is characterized by involvement of the

trapezial first metacarpal joint in all cases. However, it should
not be overlooked that there is frequently involvement of the
trapezial second metacarpal joint, the trapeziotrapezoid joint
and the trapezioscaphoid joint.

Anatomic and Radiographic Findings

The important basilar thumb joint has a unique saddle

configuration which allows the thumb to rotate in a wide arc in
which it can be brought from a flat plane of extension-abduc-
tion to a position of functional preparedness directly opposing
but well separated from the other digits. It may then be further
rotated to touch the tip or base of any of the four digits. This
wide adaptability and flexibility imparts incredible versatility to
the human hand. Arthritic deterioration of the basilar thumb
joint often renders the thumb painful and weak, depriving the
hand of considerable function.
Early radiographic findings are medial narrowing of the
carpometacarpal joint with subchrondral sclerosis of the oppos-
ing margins of the first metacarpal and trapezium (Fig. 1A).
Later, a trapezial osteophyte can be seen adjacent to the medial
base of the first metacarpal and will result in a lateral
displacement of the metacarpal base (Fig. 1B). This process of
narrowing, sclerosis, osteophyte formation and lateral subluxa-
tion may progress until there is wide separation between the
bases of the first and second metacarpals and the base of the
first metacarpal is ultimately subluxed off its trapezial seat (Fig.
1C). In advanced disease there may be a complete loss of the
trapeziometacarpal joint with collapse of the trapezium, adduc-
tion of the first metacarpal and, frequently, arthritic deteriora-
tion on all sides of the trapezium (Fig. 1D).
Dell et al [1] have classified trapeziometacarpal arthritis in
four stages correlating the x-ray findings with clinical symp-
toms, physical findings and the degree of subluxation.

Clinical Manifestations

Arthritis of the base of the thumb usually is characterized

by an insidious onset, often with pain present for many years
before the patient seeks treatment. Discomfort at the base of
ARTHRITIS/BASAL THUMB JOINTS 317

(A)
FIG. 1. X-ray appearance of arthritis of the basal joint of the thumb.
trapezio-
Narrowing and sclerosis of the medial articular surface of the
subluxa-
metacarpal joint. (B) Trapezial osteophyte formation with lateral
n of the
tion of the first metacarpal base. (C) Further lateral subluxatio
and articular destructio n. (D) Advanced pantrapezi al
first metacarpal base
of the first
arthritis with collapse of the trapezium, adduction deformity
joint.
metacarpal and hyperextension of the metacarpophalangeal

of the first
the thumb, particularly with longitudinal loading
nt complaints.
ray, weakness and clumsiness are the most freque
proble ms encoun-
Difficulty in opening automobile doors and
ntly reporte d, and
tered while doing household chores are freque
the course of one’s
there is a tendency to drop objects during
p alterna tive method s
daily activities. Patients will often develo
 J. W. STRICKLAND
318

of carrying out pain-producing tasks, and disuse atrophy of the

thenar musculature may result.
Swelling at the base of the thumb due to inflammation of
the pericapsular structures and lateral dorsal subluxation of the
base of the first metacarpal is frequently present. The “grind
test”? produced by longitudinal loading of the first metacarpal
combined with a rotatory motion will produce pain at the base
of the thumb as well as a sensation of crepitation (Fig. 2). In
later stages, first metacarpal abduction and extension become
progressively limited, and pinch and grip strength measurements
are reduced.

Management

In the early stages of this disease process, anti-inflammatory

medication or simple splinting designed to abduct the first
metacarpal and at least partially limit motion at the basilar
thumb joint may be helpful (Fig. 3). Unfortunately, this
treatment quite often is either ineffectual or provides only
transient relief of the patient’s symptom complex. At this
point, it becomes appropriate to consider the numerous surgical
procedures which have been designed to relieve pain and
preserve function in this important area.
Ligamentous reconstruction, reeommended by Michele [2]
and Eaton [3] and designed for subluxation of the first
metacarpal base without significant articular destruction, is
rarely applicable in these cases. Arthrodesis [4-7] is a reliable
pain-relieving technique which retains stability of the carpo-
metacarpal joint but has the disadvantage of eliminating its
motion. Some patients will develop excellent compensatory
motion in the trapezioscaphoid joint proximally and the
metacarpophalangeal joint distally. Others will find the loss of
basilar joint motion a substantial handicap. Excisional arthro-
plasty [8-10], which consists of excision of the trapezium, also
produces excellent pain relief. However, shortening of the first
ray and instability at the base of the first metacarpal may result
in weakness and a tendency for the metacarpal base to displace
laterally when stressed during pinch. Soft tissue interpositional
arthroplasty [1, 11] has gained considerable popularity and is a
relatively simple procedure involving the removal of the
trapezium and use of tendon-muscle material to fill the resulting
ARTHRITIS/BASAL THUMB JOINTS 319

ssion and rotation of the

FIG. 2. The “grind test” produced by compre
Pain at the carpom etacar pal joint and crepitation are
first metacarpal.
confirmatory of arthritis.
320 J. W. STRICKLAND

FIG. 3. Simple orthoplast abduction splint utilized in the conservative

management of arthritis of the basilar thumb joints.

space. As with any excisional technique, this procedure con-

sistently produces a pain-free basilar joint, although the
mobility of the first metacarpal base is somewhat variable.
Depending on individual healing factors, the joint may either be
unstable or develop a semirigid state.
Interpositional implant arthroplasty utilizing either silicone
implants [12-15] or articulated polyethylene-metal prostheses
has enjoyed increasing popularity in the management of these
problems, with the silicone implant of Swanson [12] being
commonly used. It is felt that this implant best maintains the
space created by trapezial excision and with the development of
a supportive pseudocapsule, it provides stability, mobility and
relief of pain. Unfortunately this technique was complicated by
a high reported subluxation rate in early series [16] and several
variations in the surgical technique have been recommended.
The current technical recommendations by Swanson are quite
exacting and suggest the use of the flexor carpi radialis tendon
ARTHRITIS/BASAL THUMB JOINTS 321

to reinforce the palmar capsule. The abductor pollicis longus

tendon has also been employed as a lateral reinforcement to
ensure stability of the implant. This paper will discuss the
author’s personal method, which is felt to be a simplified and
reliable technique of silicone interpositional arthroplasty uti-
lizing the implant of Swanson.

Personal Technique

The following technical procedure has been used in over 60

trapezium implants with a subluxation rate of less than 5%. It is
felt to be a fairly simple and predictable method of achieving a
pain-free, stable and mobile arthroplasty of the basilar thumb
joint.
A longitudinal incision centered over the trapezium is
utilized between the tendons of the extensor pollicis brevis and
extensor pollicis longus. Extreme care must be taken to protect
the superficial branches of the radial nerve which occur in the
snuffbox area, as well as the radial artery which passes obliquely
across the distal scaphoid in this site of exposure. The dissection
is carried down to the base of the first metacarpal and
proximally across the capsule overlying the trapezium. A
longitudinal incision is made in the capsule, which is then
sharply dissected away from the first metacarpal base to expose
the entire trapezium (Fig. 4A). A small elevator is used to
delineate the proximal and distal trapezial articulations, and the
trapezium is then removed piecemeal using a rongeur. An
important technical point is to retain a small wafer of the volar
trapezium with its edges trimmed away from the scaphoid and
first metacarpal base. This volar wafer will provide support for
the implant and obviate the need for tendon reinforcement.
With the trapezium removed and the volar wafer depressed,
the flexor carpi radialis is visible in the wound and the dome of
the scaphoid can be seen to be partially covered on its medial
slope by the trapezoid base. The amount of scaphoid covered
by the trapezium may vary from 20% to 50%, but in almost all
cases it will be necessary to remove a wedge of the trapezoid in
of
order to provide exposure of the entire curved distal surface
proper seating of the concave surface of
the scaphoid to allow
the implant (Fig. 4B and C).
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ARTHRITIS/BASAL THUMB JOINTS SAS

A triangular defect is then created in the base of the first

metacarpal and expanded by a power drill with subsequent
reaming of the medullary canal. Trial implants are then inserted
with the triangular stem fitted into the metacarpal defect to
limit stem rotation (Fig. 4D). Five implant sizes are available,
and while it is important to restore the space occupied by the
original trapezium, it is not mandatory to implant the largest
possible prosthesis; and one should look for stability during all
planes of motion when selecting the proper implant size.
Prior to definitive seating of the implant, the strip of the
abductor pollicis longus is dissected out and left attached to the
base of the first metacarpal in preparation for lateral capsular
reinforcement. After the prosthesis is seated, a .035 Kirschner
wire is driven across the base ot the first metacarpal, through
the prosthesis and into the scaphoid to secure purchase of the
prosthesis in the proper position (Fig. 4E). Capsular repair
together with reinforcement with the strip of abductor pollicis
longus is then carried out (Fig. 4F), and wound closure
completes the procedure.
in
Postoperatively, a compression dressing with the thumb
d and a
abduction is necessary for two weeks. The pin is remove
ly molded
short-arm thumb spica cast is applied which is careful
first metacar pal, but permits some degree of
around the
joint of the
anteroposterior motion at the metacarpophalangeal
examina-
thumb. Following removal of the final plaster, x-ray
of the trapezial
tion should confirm satisfactory positioning
by the trapezoid
implant on the scaphoid dome, unobstructed
(Fig. 5).
cted that there
When beginning motion, patients are instru
r joint as the
will be some initial discomfort at the basila
motion should
pseudocapsule is gradually stretched. Ultimately,
rotation. Pain relief
closely approximate normal first metacarpal
has been gratifying and consistent.

Complications

ty have included radial

Complications of implant arthroplas
metacarpophalangeal joint,
nerve irritation, stiffness of the
l syndrome.
prosthesis subluxation and carpal tunne
best avoided by careful
Radial nerve irritation can be
these structures during the
identification and protection of
324 J. W. STRICKLAND

FIG. 5. Radiographic confirmation of proper seating of the silicone

implant made possible by trapezoid excision.

surgical technique. Particularly, caution with regard to the use

of retractors on these nerves is advisable.
Stiffness of the metacarpophalangeal joint results from the
necessary six weeks of immobilization, often with inadvertent
hyperextension of the joint during the preparation of post-
operative splints or casts. This complication is best avoided by
maintaining the MP joint in slight flexion during immobilization
dressings and by an effort to allow some flexion and extension
of the joint in the final cast. A cast that is well-molded about
the first metacarpal can minimize motion at the basilar joint
and still allow metacarpophalangeal joint motion to occur. This
has proved beneficial in substantially reducing the possibility of
stiffness.
Subluxation of the implant has been the most disturbing
complication following trapezium implant arthroplasty. The
preservation of a volar support wafer, combined with trapezoid
excision, pin fixation of the implant and reinforcement of the
lateral capsule, has substantially reduced this occurrence. It is
ARTHRITIS/BASAL THUMB JOINTS 325

noteworthy that on some occasions the subluxed implant will

seat itself on the radial styloid, resulting in a remarkable degree
of stability without pain. Only when the implant subluxates
laterally or volarly and presents as a prominent mass at the base
of the thumb, or when pain complicates the displacement of the
implant, are excision and revision indicated. In these cases,
removal of the prosthesis and interposition of the pseudo-
capsule which is formed around the implant, or a portion of the
abductor pollicis longus as suggested by Welby [17], have
provided a satisfactory salvage with pain relief and satisfactory
motion and stability.
The relationship between arthritis of the basilar thumb
joint, surgical arthroplasty procedures and a higher than
expected incidence of postoperative carpal tunnel syndrome is
not well understood. Perhaps the increase in congestion within
the tunnel produced by the surgical procedure and the
postoperative immobilization is contributory. When the com-
plication occurs and does not resolve with conservative means,
division of the transverse carpal ligament may be indicated.

Summary

Arthritic degeneration of the trapeziometacarpal joint of

ly
the thumb and adjacent basal thumb joints is an extreme
on most common ly
frequent and substantially disabling conditi
may be
present in middle-aged women. Conservative treatment
ed disease will justify
palliative in an early stage, but prolong
and resectio n arthro-
surgical intervention. While arthrodesis
relief, the
plasty can be expected to predictably result in pain
follow these procedu res
loss of motion or instability which may
itional arthropl asty is
can be troublesome. Soft tissue interpos
preopera tive discomfo rt,
also a satisfactory means of relieving
following these
but stability and mobility of the thumb
implant arthroplasty,
procedures is variable. Silicone rubber
ng, is an excellent
although somewhat technically demandi
relief, while providin g thumb
means of providing long-term pain
pinch and grasp. The author
circumduction and stability during
at differen t from that
offers a technique which is somewh
to be technica lly less difficult
suggested by Swanson, but is felt
and predictably successful.
326 J. W. STRICKLAND

References

. Dell, P.C., Brushart, T.N. and Smith, R.J.: Treatment of trapezio-

metacarpal arthritis. Results of resection arthroplasty. J. Hand Surg.
3°5243-249; 1978.
. Michele, A.A.: Repair and stabilization of the first carpometacarpal
joint. Am. J. Surg. 78:348, 1950.
Eaton, R.G. and Littler, J.W.: Ligament reconstruction for the painful
thumb carpometacarpal joint. J. Bone Joint Surg. [Am.]
55:1655-1666, 1973.
. Muller, G.M.: Arthrodesis of the trapezio-metacarpal joint for
osteoarthritis. J.Bone Joint Surg. [Br.] 31:540-542, 1949.
. Leach, R.E. and Bolton, P.E.: Arthritis of the carpometacarpal joints
of the thumb. J. Bone Joint Surg. [Am.] 50:1171-1177, 1968.
. Eaton, R.G. and Littler, J.W.: A study of the basal joint of the thumb.
Treatment of its disabilities by fusion. J. Bone Joint Surg. [Am.]
51:661-668, 1969.
. Carroll, R.E. and Hill, N.A.: Arthrodesis of the carpo-metacarpal joint
of the thumb. J. Bone Joint Surg. [Br.] 55:292-294, 1973.
. Murley, A.H.G.: Carpometacarpal osteoarthritis of the thumb. Lancet
2:312, 1970.
. Gervis, W.H.: A review of excision of the trapezium for osteoarthritis
of the trapeziometacarpal joint after twenty-five years. J. Bone Joint
Surg. [Br.] 55:56-57, 1973.
. Goldner, J.L. and Clippinger, F.W.: Excision of the greater multi-
angular bone as an adjunct to mobilization of the thumb. J. Bone
Joint Surg. [Am.] 41:609-625, 1959.
. Froimson, A.: Tendon arthroplasty of the trapeziometacarpal joint.
Clin. Orthop. 70:191-199, 1970.
. Swanson, A.B. and Herndon, J.H.: Flexible (silicone) implant arthro-
plasty of the metacarpophalangeal joint of the thumb. J. Bone Joint
Surg. [Am.] 59:362-368, 1977.
. Neibauer, J.J. and Landry, R.M.: Dacron-silicone prosthesis for the
metacarpophlangeal and interphalangeal joints. Hand 3:55-61, 1971.
. Ashworth, C.R., Blatt, G., Chuinard, R.D. and Stark, H.H.: Silicone
rubber interposition arthroplasty of the carpometacarpal joint of the
thumb. J. Hand Surg. 2:345-357, 1977.
15. Haffajee, D.: Endoprosthetic replacement of the trapezium for
arthrosis in the carpometacarpal joint of the thumb. J. Hand Surg.
2:141-148, 1977.
Gs Swanson, A.B., Meester, W.D., Swanson, G.D. et al: Durability of
silicone implants — An in vivo study. Orthop. Clin. North Am.
A NOTA TO 3:
lle Weibly, A.: Surgical treatment of osteoarthritis of the carpometa-
carpal joint of the thumb; Indications for arthrodesis, excision of the
trapezium, and alloplasty. Scand. J. Plast. Reconstr. Surg. 5:136,
AG) @/ak.,
ARTHRITIS/BASAL THUMB JOINTS 327

Self-Evaluation Quiz

1. Arthritis of the carpometacarpal joint of the thumb is most

commonly found in:
Rheumatoid arthritis
Posttraumatic arthritis
Degenerative arthritis (osteoarthritis)
Following Bennett fracture
e) Following dislocation of the first metacarpal base
2. Carpometacarpal arthritis of the thumb presents most
commonly in which of the following age groups?
Middle-aged men
Middle-aged women
Elderly men
Elderly women
e) Young men
3. The most important clinical finding in the examination of
the patient with arthritis at the base of the thumb is:
Pain with strong pinch
Pain with thumb abduction
A bony prominence on the lateral aspect of the thenar
eminence
d) Pain with compression and rotation of the first meta-
carpal
e) Palpable synovitis over the carpometacarpal joint
4. Suggested methods of surgical management of carpometa-
carpal arthritis of the thumb include:
Arthrodesis
Trapezium resection
Soft tissue interpositional arthroplasty
Implant arthroplasty
e) All of the above

Answers on page 527.

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Rheumatoid Arthritis
 Surgical Treatment
of the Swan-Neck Deformity
in Rheumatoid Arthritis
Edward A. Nalebuff, M.D. and Lewis H. Millender, M.D.

Objectives

1s To present a classification of swan-neck deformities.

2. To discuss surgical management suitable for the types
of deformities identified.

There are two common finger deformities encountered in

rheumatoid arthritis: the so-called ‘‘swan-neck”’ and the “bou-
tonniére” deformities. The former is characterized by proximal
interphalangeal joint hyperextension with distal joint flexion,
whereas the latter deformity is the reverse. Neither the
swan-neck nor the boutonniére deformity is specific to rheuma-
toid arthritis. Instead they represent the end result of muscular
imbalance caused by the rheumatoid disease. As evidence of
this, we occasionally encounter patients who have both deform-
ities within the same hand in adjacent digits. There are many
of these
factors that come into play, not only in the production

of Orthopedic
Edward A. Nalebuff, M.D., Associate Clinical Professor
Medical School; Chief, Hand Service, Robert B. Brigham
Surgery, Harvard
Hospital, Beth Israel
Hospital; Orthopedic Staff, New England Baptist
Mass.; and Lewis H.
Hospital and Peter Bent Brigham Hospital, Boston,
ic Surgery, Harvard
Millender, M.D., Clinical Instructor in Orthoped
Assistant Chief, Hand Service, Robert B. Brigham
Medical School;
Hospital, Beth Israel
Hospital; Attending Staff, Peter Bent Brigham
Children’s Hospital Medical
Hospital, New England Baptist Hospital and
Surgery, Veterans Administra-
Center, Boston; Consultant in Orthopedic
tion Hospital, West Roxbury , Mass.
Clinics of North America
Reprinted, with permission, from Orthopedic
y.
6 (3):733-752, 1975. OW. B. Saunders Compan

331
Bie E. A. NALEBUFF AND L. H. MILLENDER

deformities but also in determining the extent of functional

loss. This multiplicity of causes explains the wide range of
operations recommended for patients with these deformities as
well as the confusion and diversity of opinion regarding
treatment.
In discussing the swan-neck deformity, we will classify the
deformity according to the functional loss and recommend a
program for treatment that we have found successful. Although
all swan-neck deformities have a superficial resemblance to each
other, actually they vary considerably [1]. A careful determina-
tion of the type of deformity present is essential to determine
the proper treatment. The significant functional disturbance
associated with this deformity is directly related to the loss of
flexibility at the proximal interphalangeal joint. This may vary
from no loss to partial loss to almost complete loss of flexion.
Patients with almost complete loss of proximal interphalangeal
joint flexion can be further subdivided into those with or
without preservation of joint space as seen by x-ray examina-
tion. Therefore, we find that these deformities generally fall
into one of four types, depending upon the proximal inter-
phalangeal joint mobility and the condition of the joint surface.
On the basis of this grouping, we will outline a treatment
program suitable for each specific type of swan-neck deformity.

Type 1: Proximal Interphalangeal Joints

Flexible in all Positions

Patients are seen with rheumatoid arthritis who have

swan-neck deformities with no loss of proximal interphalangeal
joint flexion. These patients demonstrate hyperextension of the
proximal interphalangeal joints with distal joint flexion, yet
maintain full flexibility of the digits. The deformity may
originate at either the distal interphalangeal or proximal
interphalangeal joint. At the distal joint it starts with either a
stretching or a rupture of the terminal extensor attachment,
resulting in a “‘mallet”’ deformity. Secondary to the distal joint
flexion, the proximal interphalangeal joint assumes a posture of
hyperextension. One can observe this sequence of events in an
untreated case. However, even in an established case, one can
suspect that this particular sequence of events has occurred if
the distal joint deformity is more severe than the proximal
SWAN-NECK DEFORMITY Boo

interphalangeal joint hyperextension (Fig. 1). In other patients

the deformity may originate at the proximal interphalangeal
joint.
Synovitis can stretch out the volar capsule, or rupture of the
superficial flexor tendon can lead to primary proximal inter-
phalangeal joint hyperextension. In these cases distal joint
flexion becomes secondary. In either case, patients with
swan-neck deformities (originating either at the distal or at the
proximal interphalangeal joint) are classified as type 1 if they
have in common the maintenance of full flexibility of the
proximal interphalangeal joint. In these patients there is only a
small functional loss related to the lack of distal joint extension.

defect at distal joint.

FIG. 1. Type 1 swan-neck deformity w.th primary
deformi ty of distal joint with secondary proximal
(A) Note mallet
Patient demonst rates full flexi-
interphalangeal joint hyperextension. (B)
interph alangea l joints. (C) Incision used for distal joint
bility of proximal
in digital posture followi ng distal
fusion. (D) There is an improvement
joint fusion in extensi on.
334 E. A. NALEBUFF AND L. H. MILLENDER

These patients usually do not have any associated metacarpo-

phalangeal joint disorder.
Treatment in these patients should be aimed at preventing
or correcting the proximal interphalangeal joint hyperextension
or restoring distal joint extension or both. Several operations
are appropriate. These include distal joint fusion, dermadesis
(volar to the proximal interphalangeal joint), flexor tenodesis of
the proximal interphalangeal joint and retinacular ligament
reconstruction.

Distal Joint Fusion

Several approaches are possible if correction of the flexion
deformity of the distal joint is needed to restore balance to the
finger. One could reattach the extensor mechanism to restore
active control of the distal joint. An alternative treatment is to
fuse the distal joint in extension. We prefer the latter approach,
particularly when the mallet deformity is primary. Otherwise
any attempt to reattach the extensor mechanism is subject to
the same rheumatoid changes that led to the deformity in the
first place. In addition, secondary arthritic changes within the
joint may make attempts to restore motion unwise.
Technique. In performing a distal joint fusion we use a
dorsal curved skin incision and divide the extensor mechanism
transversely. With the joint in flexion, the collateral ligaments
are divided to improve exposure. The articular cartilage is
removed, and the bone ends are shaped to provide good
contact. A longitudinal Kirschner wire is used for internal
fixation. In order to be certain that the wire is introduced into
the medullary canal of the middle phalanx, we predrill a small
hole into the middle phalanx before passing a slightly larger
wire in a retrograde fashion through the distal phalanx (Fig. 1).
This wire should emerge from the pulp just volar to the nail.
This wire is then reinserted across the joint into the predrilled
hole in the middle phalanx. Care should be taken not to drill
the Kirschner wire too far proximally so as to interfere with the
proximal interphalangeal joint. With this technique the distal
joint is fixed in a neutral position. This position is preferred in
the correction of the swan-neck deformity.
The Kirschner wire can be either cut off under the skin or
left exposed. Each technique has advantages and disadvantages.
SWAN-NECK DEFORMITY 335

If the wire is left exposed, it is easy to remove after fusion, and

the risk of pin tract infection is minimized. However, with this
technique the finger cannot be submerged in water and the
protruding pin must be covered to prevent injury to the patient
and others. Cutting the pin off under the skin obviates the need
for dryness and coverage but increases the risk of skin irritation,
breakdown and infection. We commonly use only one longi-
tudinal Kirschner wire for distal joint fusions but add an
obliquely placed wire to prevent rotation if necessary. In order
to facilitate fusion, we commonly add bone grafts to the fusion
site. These grafts are essential for patients in whom there are
excessive erosive changes with significant loss of bony sub-
stance. In addition, some form of external splinting is advisable
for the first four to six weeks following fusion.

Dermadesis
Dermadesis is an operative approach that is occasionally
used in patients with type 1 swan-neck deformities. In this
procedure an elliptical wedge of skin is removed from the volar
Care is
aspect of the proximal interphalangeal joint (Fig. 2).
network just under the skin. One is
taken to preserve the venous
careful not to open or disturb the underlyi ng flexor tendon
One
sheath. The skin defect is closed with the digit in flexion.
re to prevent proximal interpha langeal
attempts by this procedu
joint hyperextension by creating a skin shortage volarly.
usually
This technique is helpful only in mild cases and is
other proced ures, such as distal joint
done in conjunction with
the proxim al interp halang eal joint
fusion. In patients in whom
y, we prefer to use a stronge r checkr ein
hyperextension is primar
Our choice is flexor tenodes is, using
against hyperextension.
one slip of the flexor digitorum sublimis.

Flexor Tenodesis
Patients with excessive proximal interphalangeal joint
but with time may
hyperextension maintain full flexibility
initiating flexion. It is
begin to develop some difficulty in
strong volar support to
important in these patients to restore
of sublimis tenodesis
the joint. We prefer to use the technique
hyperextension. This
to prevent proximal interphalangeal joint
on [2], who first utilized
method has been described by Swans
336 E. A. NALEBUFF AND L. H. MILLENDER

FIG. 2. Demadesis technique. (A)

Outlineof skin incision on volar
aspects of proximal interphalangeal
joint. (B) Defect created following
skin excision. Veins and tendon
sheath have not been disturbed. (C)
Closure of defect corrects mild proxi-
mal interphalangeal joint hyperexten-
sion.

this approach in cerebral palsy patients. We have also found it

to be quite useful in rheumatoid arthritis (Fig. 3).
Technique. A volar zigzag incision is made over the
proximal interphalangeal joint, exposing the flexor tendon
sheath. The thin portion of the sheath over the joints is excised.
The flexor tendons are identified with care to avoid injury to
the vincula passing between the flexor digitorum sublimis to the
profundus tendon. One slip of the sublimis is divided % inch
proximal to the joint. This portion of the sublimis is separated
from its corresponding slip but left attached distally. This
portion of the tendon is then fixed proximally with the joint in
flexion to act as a checkrein against extension. The proximal
attachment can be made directly into the bone using a pull-out
wire technique or can be made at the thickened margin of the
flexor tendon sheath.
When attaching of the tendon to bone, we drill a small hole
perpendicular to the shaft of the proximal phalanx. A pull-out
SWAN-NECK DEFORMITY Boul

Di F
by tenodesis. (A) Mild
FIG. 3. Type 1 swan-neck deformity treated
deformity. The metacarpophalangeal joints are normal. (B)
swan-neck
(C) Zig-zag skin incision, flexor sheath opened.
Intrinsic test is negative.
vincula to profundus tendon. (D) One-half sublimis tendon to be
Note
wires. Note associated distal
attached to proximal phalanx with pull-out
(E) Postoperative extension shows correction of swan-neck
joint fusion.
deformity. (F) Postoperative flexion complete.
338 E. A. NALEBUFF AND L. H. MILLENDER

wire is used to bring the tendon into the bone and is held in
place with a pull-out wire tied over a button on the dorsum of
the finger. This attachment is stronger but more difficult than
the attachment to the margin of the fibrous sheath. In either
case one attempts to create a slight flexion contracture of the
proximal interphalangeal joint. Postoperatively the joint is
splinted in about 20° of flexion. One allows early flexion to
maintain the function, but hyperextension is blocked for at
least six weeks.

Retinacular Ligament Reconstruction

Littler [3] has devised an ingenious technique to prevent

hyperextension while restoring joint extension by reconstruct-
ing an oblique retinacular ligament using the ulnar lateral band.
In this procedure the ulnar lateral band is freed from the
extensor mechanism proximally but left attached distally. It is
then passed volar to Cleland’s fibers to bring it volar to the arc
of proximal interphalangeal joint motion. The band is then
sutured to the fibrous sheath under appropriate tension to
restore distal joint extension and prevent proximal inter-
phalangeal joint hyperextension. In theory this approach should
solve both the distal and proximal joint problems simultane-
ously. However, in the rheumatoid patient who has a primary
mallet deformity, no amount of tension applied to the relocated
lateral band will restore distal joint extension. The net result of
this procedure will then be to restrict proximal interphalangeal
joint hyperexension. Thus, this procedure in rheumatoid ar-
thritis is an alternative to dermadesis or flexor tenodesis.

Type 2: Proximal Interphalangeal Jcint Flexion

Limited in Certain Positions

There are patients with swan-neck deformities with evidence

of intrinsic tightness that restricts finger flexion only in certain
positions. The deformity may appear similar to the type 1
deformity, but on examination one can determine that the
proximal interphalangeal joint flexion is influenced by the
position of the proximal phalanx. With the metacarpo-
phalangeal joints extended or radially deviated, the patient
cannot fully flex the proximal interphalangeal joint. If the
SWAN-NECK DEFORMITY 339

metacarpophalangeal joint is allowed to flex or deviate ulnar-

ward, proximal interphalangeal joint flexibility is increased.
This is directly related to tightness of the intrinsic muscles,
particularly those on the ulnar side of the digit (Fig. 4).
This intrinsic tightness could develop in a patient who
originally had a type 1 deformity that was untreated. More
often, we see intrinsic tightness in patients who have the
primary deformity at the metacarpophalangeal joint level. The
patient develops metacarpophalangeal joint subluxation with a
secondary flexion deformity. In these patients the proximal
interphalangeal joint hyperextension is secondary to the meta-
carpophalangeal joint deformity, and the distal joint changes
follow as a result of altered balance. Thus, we might encounter
a> patient with a swan-neck deformity, with or without
metacarpophalangeal joint subluxation, who has limited proxi-
mal interphalangeal joint motion only in certain positions but is
still able to make a full fist. In these patients it is not sufficient
to restrict proximal interphalangeal joint hyperextension. One
must also relieve the intrinsic tightness and correct any
metacarpophalangeal joint disorder that initiates and prolongs
the muscular imbalance of the finger. This is accomplished by
intrinsic release (digital) in patients with normal metacarpo-
phalangeal joints and by metacarpophalangeal joint arthroplasty
with intrinsic release in the others (Fig. 4).

Intrinsic Release
h a
Technique. Digital intrinsic release is carried out throug
incisio n over the proxim al pha-
dorsal ulnar longitudinal
the ulnar
lanx [4]. The extensor mechanism is exposed, and
are identif ied and resecte d from
oblique fibers of the intrinsics
triangl e of tissue is remove d to
the extensor mechanism. A
nce. Follow ing this release, there
lessen the chances of recurre
interph alangea l joint flexion with
should be improved proximal
extend ed or radially deviate d.
the metacarpophalangeal joint
ure with distal joint fusion or
Often we combine this proced
the proxim al interph alangea l joint
volar dermadesis to correct
(Fig. 4). In
hyperextension deformity and restore balance
rpopha langea l joint disease one
patients with associated metaca
langea l joint alignme nt in
should correct the metacarpopha
same time. By using a
addition to intrinsic release at the
340 E. A. NALEBUFEF AND L. H. MILLENDER

FIG. 4. Type 2 swan-neck deformity treated by intrinsic release. (A) Note

preoperative deformity of middle and ring fingers. The metacarpo-
phalangeal joints are not involved. (B) Positive intrinsic test. Proximal
interphalangeal joint flexion is limited with metacarpophalangeal joints in
extension. (C) Intrinsic (ulnar) release carried out over proximal phalanx.
(D) Note improved digital posture following intrinsic release of middle and
ring fingers and distal interphalangeal joint fusion of middle finger. (E)
This patient has intrinsic tightness with associated metacarpophalangeal
joint flexion deformities. (F) Intrinsic release carried out proximally as
part of metacarpophalangeal joint arthroplasty.
SWAN-NECK DEFORMITY 341

transverse incision, the metacarpophalangeal joints are exposed

and the ulnar intrinsic muscles released. A metacarpophalangeal
joint arthroplasty (Swanson) with resection of the metacarpal
heads does lengthen the intrinsic muscles. However, we prefer in
addition to resect the ulnar intrinsic muscles in these cases in
order to reduce the risk of recurrent intrinsic tightness and
ulnar drift of the fingers.

Type 3: Limited Proximal Interphalangeal Joint

Flexion in All Positions

In the examples previously cited, patients have digitial

deformities but only slight to moderate functional loss. The full
significance of the swan-neck deformity is seen in patients with
marked reduction of proximal interphalangeal joint flexion in
any position. The ability to grasp objects is greatly reduced
when this occurs. No alteration of digital posture significantly
improves the patient’s grasping ability. At one time it was
thought that patients with stiff swan-neck deformities must
have advanced intraarticular changes, thereby requiring either
fusion or arthroplasty to bring the fingers into a functional
this is
position or to restore motion. Experience has shown that
not the case, for x-ray examination often reveals well-preserve d
joint spaces. Therefore, one can only conclude that additional
factors must be responsible for the lack of joint mobility.
ures
It should be obvious that none of the operative proced
fusions , dermade sis,
previously described, such as distal joint
restore motion to the
tenodesis or intrinsic release, can by itself
that soft tissue
proximal interphalangeal joint; one must assume
proximal inter-
changes have occurred at or adjacent to the
both active and passive
phalangeal joint that have reduced
to the proximal
motion. Any attempt to restore motion
correct any contrib uting
interphalangeal joint should also
l or proxim al interph a-
deformity at the metacarpophalangea
of this will reward the surgeon
langeal joint. Anything short
successes. This implies
with only occasional and short-term
langea l joint arthroplasty.
distal joint fusion or metacarpopha
With this understood, let us turn our attention to the stiff
phala ngeal joint and our attempts to
rheumatoid proximal inter
be considered and treated?
restore motion. What factors need to
re passive flexion to the
First and foremost, one must resto
342 E. A. NALEBUFF AND L. H. MILLENDER

proximal interphalangeal joint. What structures are contracted?

Can they be released or lengthened? The following structures
play a role in restricting passive motion: the extensor mech-
anism, the collateral ligaments and the skin. A number of
procedures can be utilized to restore passive motion. For our
purposes these include joint manipulation, lateral band mobili-
zation and skin release.

Proximal Interphaiangeal Joint Manipulation

In patients with stiff swan-neck deformities the soft tissues
have contracted about the joint. However, under anesthesia it is
often possible to gently manipulate the proximal interpha-
langeal joint into 80° or 90° of flexion. If the joint is flexed and
splinted in this position, the tight soft tissues will stretch. After
several weeks the passive motion obtained by this manipulation
will be maintained, provided the flexor tendons are present and
nonadherent. Proximal interphalangeal joint manipulation can
be carried out in conjunction with metacarpophalangeal joint
arthroplasty. In these patients we use Kirschner wires to hold
the proximal interphalangeal joints in flexion. This allows the
postoperative exercises to concentrate on metacarpophalangeal
joint flexion. After several weeks the pins are removed and
efforts can be directed to increase proximal interphalangeal
joint flexion. The use of proximal interphalangeal joint manipu-
lation, particularly when associated with metacarpophalangeal
joint arthroplasty or distal joint fusion, has often restored 80°
to 90° of proximal interphalangeal joint flexion in fingers that
were previously stiff (Fig. 5). A factor limiting additional
passive correction of flexion is usually the skin. Until several
years ago, this limited the amount of flexion achieved. If the
manipulation was excessive, the skin would blanch, and if not
relieved it would suffer necrosis directly over the joint. This
limitation has been overcome by making an associated skin-
relaxing incision just beyond the proximal interphalangeal joint.

Skin Release
In order to splint a previously stiff swan-neck deformity in
flexion, one must minimize tension on the skin. An oblique
incision just distal to the proximal interphalangeal joint allows
the skin edges to spread. The defect created is the result of skin
SWAN-NECK DEFORMITY 343

angeal
FIG. 5. Type 3 swan-neck deformity treated by proximal interphal
(A) There
joint manipulation and metacarpophalangeal joint arthroplasty.
even with the
is a lack of proximal interphalangeal joint flexion
at surgery following
metacarpophalangeal joints in flexion. (B) Appearance
interphalangeal joint
metacarpophalangeal joint arthroplasty and proximal
Postoperative extension
manipulation with Kirschner wire fixation. (C)
shows improved digital posture with slight residual proximal interphalange-
achieved by proximal
al joint hyperextension. (D) Range of flexion
manipula tion with metacarp ophalang eal joint arthro-
interphalangeal joint
plasty.

to three
contracture (not loss) and will gradually close over two
usly we used skin
weeks, leaving a linear scar (Fig. 6). Previo
e shrink age and
grafts to cover these defects, but their ultimat
ced us that they
the successful closure without them have convin
open allows
are not needed. In fact, the skin release left
g and pain. It is
drainage and reduces postoperative swellin
to the joint so that the
important that the skin release be distal
joint level. Althou gh joint
extensor mechanism is covered at the
are patient s in whom it
manipulation is often possible, there
344 E. A. NALEBUFF AND L. H. MILLENDER

FIG. 6. Type 3 swan-neck deformity showing use of skin release in

treatment of deformity. (A) limited preoperative proximal interphalangeal
joint flexion. (B) Appearance of skin release of index and middle fingers
three weeks following manipulation. (C) Appearance at two months. All
wounds are completely healed. (D) There is 80° to 90° of active proximal
interphalangeal joint flexion.

should not be done. One should not use much force to bring the
proximal interphalangeal joint into flexion. The soft tissues
should stretch out, not rupture. Fracture of the osteoporotic
bone must be avoided. Therefore, with the patient in whom
manipulation appears difficult one should proceed to a soft
tissue release. The procedure we use most often is lateral band
mobilizaton.

Lateral Band Mobilization

In established swan-neck deformities one finds dorsal
displacement of the lateral bands. The normal volar shift is lost
and the fingers are stiff. We have found that by freeing the
SWAN-NECK DEFORMITY 3845

lateral bands from the central slip mechanism using two

longitudinal incisions, it is possible to manipulate the joint
gently into full flexion without releasing the collateral ligaments
or lengthening the central slip (Figs. 7 and 8). Full passive
flexion can often be achieved by this method. When the
procedure is done under local anesthesia, we can ask the patient
to flex the digit and observe the shifting of the lateral bands
volarly on flexion and relocation dorsally on extension.
We first began using this procedure for swan-neck deform-
ities over ten years ago [1, 5]. The greatest problem encoun-
tered had to do with the skin. Once it was sutured, the passive
and active motion achieved by the lateral band mobilization was
lost. If one waited for the skin to heal before starting active

i Ta wll
eae D
Hh
d by lateral band mobilization,
FIG. 7. Type 3swan-neck deformity treate
Incisi on preferred for lateral band
manipulation and skin release. (A)
Exten sor mecha nism expos ed. Passive flexion severely
mobilization. (B)
te latera l bands from central slip. (D)
limited. (C) Parallel incisions separa
achiev es good proxi mal inter phalangeal flexion. Lateral
Manipulation
bands shift volarward.
 LENDER
E. A. NALEBUFF AND L. H. MIL
346

aa

Proximal interphalangeal joint of

FIG. 8. Same patient as in Figure 7. (A)
is held in flexion with a Kirsch ner wire. The skin incision is left
ring finger
x. (B) Tourni quet released. Note blanching of
open over the middle phalan
(C) Skin release reduces tension
skin on fifth finger (manipulation only).
achiev ed three weeks postoperatively. Skin
on skin. (D) Active flexion
wound s closed sponta neousl y.

operating room
motion, the degree of flexion obtained in the
incision with
was seldom achieved. We now use a curved dorsal
incision is closed
an oblique leg across the middle phalanx. The
It is usually
proximally with the finger held in flexion.
open. The
necessary to leave the distal third of the incision
to stretc h the
finger is splinted in this position for several weeks
necess ary to
contracted lateral ligaments. In some cases it is
l slip in a
release these ligaments as well as to lengthen the centra
to achiev e
stepwise fashion. These patients should be able
flexio n postop erativ ely if the flexor tendon s are
satisfactory
assess the
present and nonadherent. For this reason one must
e motio n
activity of the flexors as well in order that the passiv
SWAN-NECK DEFORMITY 347

gained by the soft tissue release or by manipulation will be

maintained postoperatively.
The role of the flexors in the establishment or maintenance
of limited digital motion can be determined preoperatively.
However, the ultimate test is the patient’s ability to actively
flex the proximal interphalangeal joint as much as is possible
passively. In order to avoid the disappointment of poor results,
an effort should be made to determine the status of the flexors
while the patient is still in the operating room. This can be done
in several ways. By using intravenous regional or local anesthesia
it is possible to obtain the patient’s cooperation to see whether
active motion matches the passive mobility. Following restora-
tion of passive proximal interphalangeal joint motion by either
manipulation or lateral band mobilization (with or without skin
release), the tourniquet can be released. Within minutes the
patient regains motor control and can be asked to flex the
finger. If a discrepancy is encountered, one must reinstitute
anesthesia and explore the flexor apparatus, freeing up ad-
hesions or removing any flexor tendon nodules that are
interfering with tendon excursion. An alternate approach that
we find useful is to expose and apply traction to the flexor
tendons in the palm [1]. One soon learns whether the flexor
tendon excursion is normal and utilizes all of the passive
proximal interphalangeal joint flexion.
In many cases flexor tendon nodules will be found within
the digit so that a more extensive tenosynovectomy is needed to
achieve improved excursion of these tendons (Figs. 9 and 10).
In some of these cases one can assume that the flexor tendon
disease was primary in the development of limited proximal
interphalangeal joint motion. By first restoring passive motion
and then checking and restoring active motion, we have been
able to restore almost full flexion to digits that were quite stiff
preoperatively. Of course, supervised postoperative splinting
and exercises are needed to maintain the gains achieved
surgically.

Type 4: Stiff Proximal Interphalangeal Joints

with Poor X-ray Appearance

What has been written to this point applies to the

If the
restoration of motion in joints that are worth preserving.
348 E. A. NALEBUFF AND L. H. MILLENDER

FIG. 9. Type 3 swan-neck deformity treated by proximal interphalangeal

joint manipulation and flexor tendon release. (A) Preoperative extension.
Patient prepared for intravenous regional anesthesia. (B) Maximal active
flexion. (C) Full passive flexion obtained under anesthesia. (D) A solid-line
incision is chosen to expose all the tendons in the palm and the index
flexors within digits. Dotted lines show incisions to be used if needed.

joint surfaces are badly eroded and are unstable, alternate

methods should be considered. This brings us to the next type
of swan-neck deformity — patients who have stiff proximal
interphalangeal joints with x-ray evidence of advanced intyra-
articular changes. In these patients some form of salvage
procedure is needed.
What are the factors that influence our decision? The
factors that must be considered are the fingers involved, the
status of adjacent joints, the status of supporting structures and
the status of the flexor tendons. With this in mind, when would
we tend to favor fusion for this type of “‘stiff’? swan-neck
deformity? We tend to prefer fusion to arthroplasty in the
index and middle digits. Lateral stability is particularly impor-
tant in those patients and less important than flexion. The
status of adjacent joints is also important. If the metacarpo-
phalangeal joints require arthroplasty, we would favor fusion at
SWAN-NECK DEFORMITY 349

FIG. 10. Same patient as in Figure 9. (A) Note extensive flexor

tenosynovitis. (B) Following release of flexor tendons, traction achieves
digital flexion. (C) Postoperative extension at three weeks. (D) Excellent
active flexion was achieved.

the proximal interphalangeal joint level. Poor lateral ligament

support or associated flexor tendon ruptures would also tilt our
approach toward fusion (Fig. 11).

Proximal Joint Fusion

When performing a proximal interphalangeal joint fusion in
rheumatoid arthritis, we use longitudinal skin incisions, splitting
to
the extensor mechanism longitudinally. The joint is flexed
expose the articular surfaces, which are prepare d from fusion.
crossed
Unlike distal joint fusions, we routinely use two
fixation . The position s of
Kirschner wires to obtain internal
digit involved and the sex of the
fusions vary according to the
less flexion is chosen for the index
patient. As a general rule,
The degree of
finger as compared to that for the middle digit.
s toward the smaller finger. The
flexion increases as one proceed
varies from 95° to 45 .)When
amount of flexion chosen
interph alangea l joint fusion in female
performing a proximal
use less flexion than the so-calle d
patients, we tend to
functional positions.
350 E. A. NALEBUFF AND L. H. MILLENDER

D 4
FIG. 11. Type 4 swan-neck deformity suitable for proximal joint fusion.
(A) Patient with severe swan-neck deformity of index finger with
associated deformities; fusion of the proximal interphalangeal joint is our
treatment of choice. (B) This patient with lateral instability and swan-neck
deformity of ring finger is a candidate for proximal interphalangeal joint
fusion. (C) This patient has a fixed swan-neck deformity of the middle
finger associated with flexor tendon ruptures. (D) Postoperative ap-
pearance of hand following digital fusion with metacarpophalangeal joint
arthroplasty.

Arthroplasty
We will often carry out proximal interphalangeal joint
Swanson arthroplasties for the stiff swan-neck deformity if the
adjacent joints, soft tissues and tendons are intact. This is our
preference, particularly in the ring and small fingers. A dorsal
curved incision is used. The extensor mechanism is exposed and
split longitudinally. The distal end of the proximal phalanx is
removed and the medullary canal prepared for the insertion of
the prosthesis. One should preserve the collateral ligaments for
reattachment following insertion of the prosthesis. We feel that
two important factors in the management of the stiff, rheuma-
toid proximal interphalangeal joint (type 3) are of value here as
well: the factor of a tight dorsal skin and the status of the
SWAN-NECK DEFORMITY atyll

flexor apparatus. Skin closure is carried out with the joint in

slight flexion with the distal portion of the wound left open, if
necessary, in order to avoid extensive skin tension. In addition,
a palmar incision may be made and the flexor tendons tested to
be certain that their excursion is intact (Figs. 12 and 13).
Postoperatively the fingers are splinted in 20° to 30° of flexion
with early institution of passive and active exercises.

Summary

Swan-neck deformities vary not only in origin but also in

the extent of functional loss. Careful examination used to
determine the degree of flexion in all positions, as well as x-ray
examination of the joint, has allowed us to group these patients
into four types. Various surgical procedures are recommended
according to this classification, which has made the treatment
of these patients more orderly and rewarding.

by proximal interphalangeal
FIG. 12. Type 4 swan-neck deformity treated
extensi on; severe deformity noted. (B)
joint arthroplasty. (A) Preoperative
limitat ion in flexion of proxim al interph alangeal joint. (C) X-ray
Marked
proxim al interph alangeal joint of index
view shows severe changes of
marked narrow ing of other proxim al interphalangeal joints.
finger, with
Hand functio n is greatly reduced.
(D) Volar view on attempted grasp.
SoZ, E. A. NALEBUFF AND L. H. MILLENDER

FIG. 13. Same patients as in Figure 12. (A) Postoperative view shows
improved posture of fingers. (B) Use of tape to splint fingers during early
postoperative period. (C) Volar view showing digital extension and palmar
incision used to check flexor tendon function. (D) Active proximal
interphalangeal joint flexion. Note closure of distal portion of skin incision
left open at surgery.

References

1. Nalebuff, E.A.: Surgical treatment of finger deformities in the

rheumatoid hand. Surg. Clin. North Am. 49:833-846, 1969.
2. Swanson, A.B.: Surgery of the hand in cerebral palsy and the swan
neck deformity. J. Bone Joint Surg. 42:951-964, 1960.
3. Littler, J.W.: Restoration of the oblique retinacular ligament for
correction of hand. G.E.M. No. 1, Paris, L’Expansion, 1966.
4. Littler, J.W., quoted by Harris, C., Jr. and Riordan, D.: Intrinsic
contracture in the hand and its surgical treatment. J. Bone Joint Surg.
36A:10-20, 1954.
5. Nalebuff, E.A., Potter, T.A. and Tomaselli, R.: Surgery of swan neck
deformity of the rheumatoid hand: A new approach, abstracted.
Arthritis Rheum. 6:289, 1963.

Bibliography
Flatt, A.E.: The Care of the Rheumatoid Hand. St. Louis:C. V. Mosby
Co., 1974.
Leach R.E. and Baumgard, S.H.: Correction of swan neck deformity in
rheumatoid arthritis. Surg. Clin. North Am. 48:661-686, 1968.
SWAN-NECK DEFORMITY 353

Swanson, A.B.: Silicone rubber implants for replacement of arthritic or

destroyed joints in the hand. Surg. Clin. North Am. 48:1113-1127,
1968.
Swanson, A.B.: Flexible implant arthroplasty for arthritic finger joints. J.
Bone Joint Surg. 54A:435-455, 1972.
Swanson, A.B.: Flexible Implant Resection Arthroplasty in the Hand and
Extremities. St. Louis:C. V. Mosby Co., 1973.

Self-Evaluation Quiz

1. Swan-neck and boutonniére deformities are specific to

rheumatoid arthritis.
a) True
b) Ealse
2. In the type 1 deformity, treatment is aimed at preventing or
correcting distal joint hyperextension and restoring prox-
imal joint extension.
a) True
b) False
3. The preferred procedure to correct a primary flexion
deformity of the distal joint is:
a) Reattachment of extensor mechanism
b) Dermadesis
c) Distal joint fusion
4. Dermadesis is usually helpful only in mild cases.
a) True
b) False
5. To restrict proximal interphalangeal joint hyperextension,
an alternative to dermadesis or flexor tenodesis in the
patient with rheumatoid arthritis is retinacular ligament
reconstruction.
a) True
b) False
decreases
6. In intrinsic release, removal of a triangle of tissue
the chance of recurrence.
a) True
b) False
is preferred
7. As a salvage procedure, proximal joint fusion
over arthroplasty if:
a) Index and middle digits are involved
b) Ring and small fingers are involved
 E. A. NALEBUFF AND L. H. MILLENDER
354

c) Metacarpophalangeal joints require arthroplasty

d) Adjacent joints, soft tissues and tendons are intact
e) Flexor tendon ruptures are present

Answers on page 527.

 Thumb Problems in Rheumatoid
Arthritis

John S. Gould, M.D.

Objectives

1. To delineate the pathologic processes in all components

of the rheumatoid thumb.
2% To clarify the physical and functional deficits which
occur when each component is involved with prolifera-
tive synovitis.
3. To discuss the various appropriate reconstructive pro-
cedures available for each component deficit.
4. To emphasize the concept of total component recon-
struction, simultaneously performed, in order to
achieve a successful result at each level and to provide
stability, strength and dexterity to the thumb and the
hand.

nents of
Proliferative synovitis may affect multiple compo
ing tendon s, nerves and joints;
the rheumatoid thumb, includ
loss of mobili ty, frank joint
resulting in pain, instability,
n imbala nce, loss of sensibi lity and
dislocation, weakness, tendo
Goals of recons tructi on includ e relief
ultimate loss of function.
strength and dexterity.
of pain and restoration of sensibility,
mobili ty are desirable in the thumb,
Whereas both stability and
ty may be sacrificed to
stability is paramount and some mobili
In the rheumatoid thumb,
achieve the most functional member.
the composite of the three
with multiple components involved,
ered simultaneously, as
joints and active motors must be consid
the fingers, when planning
well as the position and condition of
reconstruction.

Professor of Orthopaedic Surgery;

John S. Gould, M.D., Associate Center,
University of Alabama Medical
Chief, Section of Hand Surgery,
Birmingham.

355
356 J. S. GOULD

Tenosynovitis and Tendon Rupture

Tenosynovitis within the carpal tunnel may produce pares-

thesias, hypesthesia and pain in the thumb, as well as elsewhere
in the median nerve distribution. Motor weakness in thenar
intrinsics secondary to compression of the recurrent motor
branch, as well as thenar atrophy or paralysis, may occur.
Tenosynovitis involving the flexor pollicis longus may produce
pain, loss of active motion in the thumb and even frank rupture
of the tendon as it exits from the carpal canal. Release of the
deep volar ligament, tenosynovectomy of the flexors, including
the flexor pollicis longus, and neurolysis of the median nerve
should relieve pain, increase tendon mobility, possibly improve
decreased sensibility, possibly retrieve the intrinsic weakness
and hopefully protect the tendons from future rupture.
Flexor tenosynovitis within the thumb is less commonly
recognized than in the digits, but frequently occurs, and is
manifested by pain, crepitus on palpation over the sheath, lack
of active motion and triggering. Treatment is tenosynovectomy,
possibly incision of the transverse pulley over the metacarpo-
phalangeal joint level, and preservation of the long oblique
pulley over the proximal phalanx.
If flexor pollicis longus rupture has occurred, direct suture
is rarely possible; a segmental graft can be considered. A free
graft from the proximal motor at the wrist to the end of the
thumb is a possibility if there is reasonable elasticity in the
proximal muscle. If not, the flexor digitorum superficialis of the
ring finger can be used as a transfer. The anastomosis should be
at the insertion of the flexor pollicis longus, not in the carpal
canal where it will adhere, in the thenar zone where accessibility
is poor, or under the thumb pulleys. The postoperative
management of the flexor synovectomy requires early mobiliza-
tion; the graft or transfer requires a period of immobilization or
limited mobility; hence, a later one-stage graft or transfer, or
initial placement of a silicone or silicone-Dacron tendon rod,
and a second-stage graft or transfer is advisable. The two-stage
procedure allows immediate mobilization after the first stage,
and then entry only at the wrist and the end of the thumb
secondarily. We have preferred this latter approach.
Rupture of the extensor pollicis longus in the third
fibro-osseous extensor compartment at the level of Lister’s
RHEUMATOID THUMB PROBLEMS 357

tubercle is common, and is detected by lack of a palpable

tendon when extending the interphalangeal joint of the thumb
against resistance. When we perform an extensor tenosynovec-
tomy, we routinely reroute the extensor pollicis longus from
around the tubercle to prevent this rupture, which is felt to
occur from a combination of deprived tendon nutrition by the
synovitis and bony attrition. Although a segmental graft can be
considered, if the proximal motor is inelastic, a transfer of the
extensor indicis proprius, detached proximal to its hood
insertion, is a reasonable reconstructive maneuver.
Attenuation of the extensor pollicis brevis at the metacarpo-
joint
phalangeal joint level, secondary to metacarpophalangeal
in a common ly seen imbalan ce of the thumb,
synovitis, results
The
coined by Nalebuff as the ‘“extrinsic-minus” deformity.
ngeal joint assumes a flexed position , the
metacarpophala
brevis and adducto r pollicis aponeur oses
abductor pollicis
hyper-
migrate volarly, and the interphalangeal joint becomes
problem
extended and loses flexion. Management of the joint
attended to
will be considered in a later section, but it must be
to prevent
simultaneously with the tendon reconstruction
asty is done,
recurrence. If a joint synovectomy or arthropl
imbricated the
tendon reconstruction is mandatory. We have
advancement of
attenuated extensor pollicis brevis with dorsal
tissues are severely
the intrinsics in most instances, but if these
will be done,
compromised, or if interphalangeal joint fusion
longus to the base
proximal attachment of the extensor pollicis
interphalangeal joint
of the proximal phalanx is preferred. If the
will be performed by
will remain mobile, extension at this level
the intrinsics.
mechanism at the
Rupture of the conjoined extensor
in the joint is again
interphalangeal joint from synovitis
joint itself. If arthrodesis
managed according to the plan for the
tion is not necessary. If
is done at this level, tendon reconstruc
e, a segmental graft is a
the joint is stable and passively mobil
fusion is the usual choice in
possibility. This procedure or joint
of the flexor digitorum
the rheumatoid thumb, but transfer
the distal phalanx of the
superficialis of the ring finger to
struction over the
thumb is a consideration. Pulley recon
to maint ain alignment of the
proximal phalanx is necessary
transfer.
358 J. S. GOULD

Tenosynovitis in the first extensor compartment, involving

the abductor pollicis longus and extensor pollicis brevis, results
in pain and loss of thumb mobility. It is less commonly seen in
the rheumatoid thumb than involvement of the other compart-
ments, but does occur. Tendon ruptures are exceedingly rare.
Release of the compartment and tenosynovectomy should
relieve the problem.

Carpometacarpal Joint

Involvement of the carpometacarpal joint results in pain and

loss of mobility. Abduction, extension and pronation are
limited, leading to a significant loss of dexterity. Grasping large
objects becomes difficult and pinch is limited by pain and lack
of pronation for good opposition. The metacarpophalangeal
joint compensates by hyperextending. As the metacarpal
subluxes on the trapezium dorsally and radially, a significant
imbalance occurs with metacarpophalangeal joint hyperextension
and interphalangeal joint flexion. Restorative procedures at this
level are multiple, but each has in common, relief of pain,
increased mobility and the return of tendon balance. Arthro-
desis of the trapezial-first metacarpal joint is not a consideration
here, due to the peritrapezial disease present or expected to
occur, and the possible necessity of arthrodesis in the distal
thumb joints.
Resection of the trapezium is one of the earliest procedures
and is still preferred by many surgeons. It is now usually
combined with an adductor pollicis or web space release, if
necessary; and an insertion of an ‘‘anchovy” (a rolled up
segment of tendon) as a spacer. Many surgeons will also add
stabilization of the metacarpal with a slip of the flexor carpi
radialis, reconstruction of the dorsal capsule with a slip of the
abductor pollicis longus, and imbrication of the remaining
abductor pollicis longus. Tendon reconstructions are also
frequently incorporated with the prosthetic arthroplasty tech-
niques. We use the resection technique in patients with a
metacarpal medullary canal too small to accept a prosthesis, as
in a juvenile rheumatoid thumb, or after a failed prosthesis. The
technique provides pain relief and mobility, although pinch
strength gains are minimal and thumb shortening occurs.
Stabilization of the metacarpophalangeal joint in slight flexion
with a temporary K wire, volar plate reefing or arthrodesis of
RHEUMATOID THUMB PROBLEMS 359

the joint is essential if there is any tendency for hyperextension,

to prevent subluxation of the metacarpal base (and prosthesis, if
it is attached).
Multiple prostheses are available and each have their
advocates. Current models in vogue include the silicone trapezi-
um replacement of Swanson, with the stem inserted into the
metacarpal shaft. Although dislocations were not uncommon
despite stabilization with the flexor carpi radialis, the current
high-performance silicone model may be sutured into the flexor
carpi radialis or pinned in place until encapsulation is complete.
Eaton has designed a similar silicone model with a hole through
the trapezium spacer to allow the surgeon to thread a tendon
(APL) for stability. The Niebauer silicone-Dacron prosthesis has
ties at the base of the stem to secure it to the base of the
metacarpal, and an additional larger tie to provide attachment
to the underlying flexor carpi radialis or to the adjacent second
metacarpal. A partial resection of the trapezium with insertion
of the short stem of a silicone prosthesis into the remainder of
the carpal has recently become popular (hemi-Swanson, Swan-
son great toe prosthesis) due to reported greater stability.
Finally, several metal alloy /high-density-polyethylene articu-
and
lated prostheses, which are cemented into the trapezium
de
metacarpal shaft, after partial resection, are available (Mayo,
and may
la Caffiniere). These are currently under investigation
applicable to the patient with degenerative arthritis
be more
is with the
than to the rheumatoid. Our major experience
of this
Niebauer silicone-Dacron model. In over 50 prostheses
results with
type inserted, we have experienced satisfactory
Pinch strength
relief of pain, stability and increased dexterity.
are minimal: no
has only been slightly improved. Complications
the implant, no
infections to date, one sterile reaction to
failure to resect
dislocations and three subluxations due to
prosthesis at surgery.
sufficient trapezoid to properly seat the
are retrievable with the removal of the
Complications
have reported
prosthesis, leaving a resection. Other surgeons
similar good results with recent silicone models.

Metacarpophalangeal Joint
joint results in pain,
Synovitis in the metacarpophalangeal
remains stable and the
instability and deformity. If the joint
360 J. S. GOULD

articular surfaces are intact, synovectomy of the joint is

appropriate. Reconstruction of the ‘“‘extrinsic-minus”’ deform-
ity, noted above, may accompany the synovectomy.
With stability but loss of articular surfaces, a silicone or
silicone-Dacron arthroplasty, preserving the collateral ligaments,
may be done. The largest prosthesis that can be inserted should
be used and soft tissue reconstruction is critical, as silicone
prostheses have poor lateral stability. Several metal alloy/high-
density-polyethylene hinged prostheses cemented into the
metacarpal and proximal phalanx (descendants of the Flatt
metal hinge model) have been designed which provide motion
and lateral stability. Experience is just now being gained with
these models. We have no experience with the cemented
prostheses, avoiding, at least on theoretical grounds, the risks of
using cement in these bones with minimal soft tissue cover.
Time and experience will be the ultimate judge of the fate of
these designs. We have used the silicone-Dacron model, achiev-
ing satisfactory lateral stability and an average of 20° of
motion.
Cone arthrodesis of the joint is the procedure of choice
when instability and surface loss are present. The fusion should
be in 20° of flexion, about 10° of radial angulation and enough
pronation to allow 3 jaw chuck pinch to the index and long
digits. The choice between arthrodesis and silicone or silicone-
Dacron arthroplasty is made after considering the residual joint
stability, the mobility of the two adjacent joints and the
expected requirements of the hand — taking into consideration
the age, sex and occupation of the patient.

Interphalangeal Joint
Pain and instability of the interphalangeal joint is usually
managed by arthrodesis. This is performed essentially in full
extension. A silicone stemmed spacer is available, but excellent
collateral ligaments and good flexor and extensor function
would be essential for a good result. In my experience, these
prostheses are rarely used in the thumb.

Conclusions
As noted in the preceding sections, reestablishing stability
with as much mobility as possible at the basilar joint is the key
RHEUMATOID THUMB PROBLEMS 361

to good function in the thumb. Stability at this level also

demands relief of an adduction contracture and stabilization of
the metacarpophalangeal joint. If maintenance of metacarpo-
phalangeal or interphalangeal joint mobility is feasible, func-
tioning tendons must be present or reconstructed. If arthrodesis
at the distal levels is indicated, less tendon reconstruction may
be needed. Tenosynovectomy on the flexor side should always
be considered when arthroplasty is done at the metacarpopha-
langeal joint level. Finally, reconstruction at all three joint
levels, and of the tendons, can and often should be done
concomitantly, if indicated.

Self-Evaluation Quiz
s

1. Tenosynovitis within the carpal tunnel may affect which of

the following in the thumb?
a) Loss of active motion
b) Loss of sensibility
c) Intrinsic weakness
d) Rupture of the long flexor
e) All of the above
other
2. Along with release of the deep volar ligament,
procedures which may be needed in the carpal tunnel of the
rheumatoid thumb may include:
a) Tenosynovectomy
b) Neurolysis of the median nerve
c) Tendon rupture reconstruction
d) All of the above
involved with
3. Extrinsic thumb motors which may be
synovitis include all of the followin g except:
a) Extensor pollicis longus
b) Extensor pollicis brevis
c} Adductor pollicis
d) Abductor pollicis longus
e) Flexor pollicis longus
4. The “extrinsic-minus” deformity refers to:
a) Rupture of the extensor pollicis longus
b) Rupture of the flexor pollicis longus
mechanism at
c) Attenuation of the conjoined extensor
the interphalangeal joint
362 J. S. GOULD

d) Attenuation of the extensor pollicis brevis at the

metacarpophalangeal joint, with volar migration of the
intrinsic aponeuroses
e) All of the above
Degenerative changes in the rheumatoid carpometacarpal
joint of the thumb can be reconstructed by all of the
following except:
a) Excision of the trapezium
b) Arthrodesis of the trapezial-first metacarpal joint
c) Prosthetic arthroplasty
Reconstruction of the metacarpophalangeal joint may in-
clude all of the following except:
a) Synovectomy
b) Excisional arthroplasty
c) Tendon reconstruction
d) Prosthetic arthroplasty
e) Arthrodesis
Interphalangeal joint arthroplasty is the procedure of choice
in the rheumatoid thumb.
a) True
b) False
Only one joint should be reconstructed in the thumb at a
time, rather than simultaneously, so that the result in each
can be assessed before moving on to the next level.
a) True
b) False

Answers on page 527,

 Dorsal Swellings of the Wrist:
Diagnosis and Treatment
F. William Bora, Jr., M.D. and Robert R. Kaneda, D.O.

Objectives

1. To review the various causes of dorsal wrist swelling.

2. To present alternative surgical management when con-
, servative measures are unsuccessful.
3. To emphasize the importance of preoperative and
postoperative clinical evaluations.

Swelling on the back of the wrist may be caused by trauma,

benign cyst (ganglion), neoplasia, inflammatory and metabolic
diseases. Tissues which may produce swelling include skin,
subcutaneous tissue, fascia, nerves, arteries, tendons, synovium,
muscle, cartilage and bone.
Rucurrent trauma to the dorsum of the hand causes
hemorrhage around the extensor tendons, which provokes
fibroblasts to produce collagen and other ingredients that
comprise fibrous tissue as seen in extensor peritendinous
fibrosis (Secretan disease) [1]. This intriguing syndrome pre-
be
sents as a swelling on the dorsum of the hand and should
treated conservatively for at least one year. Splinting and
and
limited activity usually helps to control the dorsal swelling
tendon gliding, but the surgical removal of
its effect on extensor
help patients who do not respond to a
the fibrous tissue does
prolonged conservative program.
fistulas are
Most aneurysms, varicosities and arteriovenous
by injury or infecti on. These swellin gs may
congenital or caused
pressu re or elevat ion of the extrem ity,
be emptied by digital

Kaneda, D.O., Department of

F. William Bora, Jr., M.D. and Robert R.
of Philadelphia, Philadelphia, Pa.
Orthopedics, Hospital of the University

363
364 F. W. BORA, JR. AND R. R. KANEDA

and they increase the temperature in the surrounding tissues. A

bruit can be heard in 50% of the cases. Arteriosclerotic
aneurysms are rare, but are found on the dorsum of the hand
and usually pulsate. The cavernous hemangioma is diffuse,
causes pigmentation and is usually present at birth.
Dorsal and volar hand infections may present as swellings on
the dorsum of the hand. Cellulitis or collections of pus provoke
a surrounding inflammatory reaction and interstitial edema is a
major part of this reaction. The volar skin is firmly adherent to
the underlying palmar fascia and the flexor tendon sheath so
that reactive edema may be directed from any volar compart-
ment infections to the dorsum of the hand.
A ganglion (Fig. 1) may appear as a discrete, well-encapsu-
lated mass or as a multiple, diffuse swelling and is the most
common swelling of the hand. Its cause is obscure but the
following etiologies have been reported: retention cyst, meta-
plastic transformation, synovial herniation and capsular degen-
eration. Arthrography of the wrist by Andren and Eiken [2]
showed a communication between the wrist and the ganglion in
14 of 32 cases, but the injection of the ganglion failed to show a

FIG. 1. A dorsal ganglion, the most common swelling on the dorsum of

the hand.
DORSAL WRIST SWELLING 365

wrist connection and a. valve mechanism was hypothesized as

being responsible. Ganglia appear to arise from the wrist joint
capsule or the fibrous element of the tendon sheath, and pain is
a frequent symptom in patients who use their hands on their
jobs or in their avocations. Adair, Pack and Farrior [3] reported
on 352 lipomas, of which only 2 were located in the dorsum of
the hand and wrist, which emphasizes the rarity of this lesion in
this area. Inclusion cysts, foreign body granulomas and carpal
bossing are dorsal masses which can be surgically removed if the
symptoms compromise hand function. Hypertrophy of an
extensor muscle (extensor digitorum brevis manus, Fig. 2) and
simple giant cell tumors are also dorsal swellings which may be
left untreated unless the patient’s symptoms dictate removal.
Bony swellings, such as osteochondromas, enchondromas,
osteoid osteomas and osteomyelitis, produce soft tissue swell-
ings which can cause symptoms; roentgenograms in such cases
are mandatory because a soft tissue biopsy will show a reactive
tissue lesion and fail to uncover the proper tissue pathology.
Gout, multiple xanthoma and rheumatoid arthritis are
metabolic diseases which cause dorsal wrist swelling. Gout (Fig.

manus, anomolous intrinsic

FIG. 2. The extensor digitorum brevis
extensor muscle on the dorsum of the hand.
366 F. W. BORA, JR. AND R. R. KANEDA

3), a defect in uric acid metabolism, produces gouty tophi when

untreated. If conservative management fails to eliminate the
functional abnormalities caused by the tophus, its surgical
removal is indicated. Multiple xanthoma, a disorder of lipid
metabolism, produces nontender, subcutaneous nodules which
can compromise joint motion and/or tendon gliding. The
surgical removal of these masses is indicated if they mech-
anically interfere with hand and/or wrist function.
Approximately 5 million people in the United States are
affected with rheumatoid arthritis, 75% of whom have hand
involvement [4]. A frequent site of hand involvement is in the
synovium around the extensor tendons over the dorsal aspect of
the hand and wrist and, when present, presents as a swelling in
that area. Conservative management, including proper drugs,
splints and hand therapy, will prevent a high percentage of hand
deformities. Persistent dorsal synovitis in patients under good
conservative management, however, makes them candidates for
surgical treatment [5]. Extensor tendons have a synovial lining
as they pass under the extensor retinaculum in their tight
fibro-osseous space on the back of the radius. Synovial

FIG. 3. Tophaceous gout.

DORSAL WRIST SWELLING 367

proliferation (Fig. 4), therefore, limits tendon gliding in this

area, which restricts wrist and digital motion. Dorsal dislocation
of the distal ulna, a common joint deformity, impails the
extensor tendons (especially to the ring and small digits) in this
unyielding area, which further limits tendon motion and hand
function [6]. Also, the release of lysosomes during the active
phase of the disease degrades tendon collagen, which weakens
its tensile strength. Unless conservative therapy controls the
local rheumatoid disease on the dorsum of the hand, the
excessive synovium, ulnar styloid dislocation and lysosome
release will lead to tendon rupture.
The size of the swelling, pinch and grip strength, and wrist
and finger motion are measurable findings one can follow to
determine the effect of the conservative therapy being used. If
these measurable signs worsen with accepted conservative
therapy, dorsal synovectomy is indicated. A straight incision on
the dorsum of the hand and wrist exposes the extensor
retinaculum. The extensor retinaculum is incised in line with
the extensor digiti minimi and retracted laterally. Dissection is

wrist swelling in patients with

FIG. 4. Synovial proliferation causing dorsal
rheumatoid arthritis.
368 F. W. BORA, JR. AND R. R. KANEDA

extended as far as the combined sheath of the abductor pollicis

longus and extensor pollicis brevis. After removal of Lister’s
tubercle and the dorsal aspect of the distal ulna (if indicated),
the extensor retinaculum is sutured to itself, deep to the
exposed tendons and dorsal to the exposed bone (Fig. 5).
Excessive synovium is then removed from the extensor tendons;
however, a recent article [7] has recommended only extensor
tendon synovial decompression, rather than excision, and claims
an 81.5% complete resolution of the synovium in 54 wrists
(postsurgery). Persistent dorsal synovitis causes extensor tendon
rupture which compromises power grip and pinch (Fig. 6).
Tenorrhaphy, tendon graft and tendon transfer are the surgical
options for the treatment of extensor tendon rupture. Tenor-
rhaphy of the ends of the ruptured tendons fails because the
collagen in the tendon ends lacks the tensile strength to hold
the suture; but intratendinous suture is possible by attaching
the ruptured small and ring finger extensor tendons to the long
finger tendon when the latter is intact and such a clinical
situation exists. Tendon grafting (Fig. 7) using the palmaris

FIG. 5. The extensor retinaculum placed deep into the extensor tendons
after synovectomy.
DORSAL WRIST SWELLING 369

FIG. 6. Rupture of extensor tendons to ring and small finger.

sp ct
ial

is longus to reconstruct the

FIG. 7. A loop tendon graft utilizing palmar
extrinsic extens ors to the ulnar digits.
370 F. W. BORA, JR. AND R. R. KANEDA

longus has given satisfactory results, as has transferring the

extensor carpi radialis longus to the ruptured distal ends of the
extensor digitorum communis tendons. Extensor tendon sur-
gery is protected for one month, after which hand therapy is
begun.
Preoperative and postoperative evaluations are necessary to
assess the value of the surgery, just as similar clinical evaluations
are needed to assess the value of the conservative therapy.
Specific clinical measurements of the size of the dorsal swelling,
the amount of wrist and digital motion, power pinch and power
grip measurements, as well as sensibility, should be recorded in
the clinical chart. It is also important to have surgically treated
patients enrolled in a well-organized hand therapy program to
obtain the maximum functional results after surgery.

Conclusion

A swelling of the dorsum of the hand and wrist can be

treated satisfactorily only after a diagnosis is made. If the
space-occupying mass causes symptoms and compromises the
ability of the patient to perform his or her activities, surgical
removal is indicated. If the swelling is a local manifestation of
rheumatoid arthritis, a period of at least six months of
conservative therapy is indicated before surgery should be
considered. Dorsal synovitis resistant to conservative therapy
should be surgically removed because tendon rupture is a
predictable complication. Tendon ruptures caused by rheuma-
toid arthritis may be treated by tenorrhaphy to an adjacent
intact tendon, tendon graft or tendon transfer [8]. We have had
good results from transferring the extensor carpi radialis longus
to the proximal end of the ruptured extensor digitorum
communis tendons. Preoperative and postoperative clinical
evaluation sheets are necessary so that the surgical treatment
rendered may be evaluated.

References

— . Saferin, E.H.: Secretan’s disease. Plast. Reconstr. Surg. 58:703, 1976.

2. Andren, L. and Hiken, O.: Arthrographiec studies of wrist ganglions. J.
Bone Joint Surg. 53A:299-302, 1971.
38. Adar, F.E., Pack, G.T. and Farrior, H.G.: Lipomas. Am. J. Cancer
16:1104-1120, 1932.
 DORSAL WRIST SWELLING all

4. Dobyns, J.H. and Linscheid, R.L.: Rheumatoid hand repairs. Orthop.

Clin. North Am. 2 (3):629-645, 1971.
5. Nalebuff, E.: Surgical treatment of rheumatoid tenosynovitis in the
hand. Surg. Clin. North Am. 49 (4):799, 1969.
6. Ehrlich, G.E., Peterson, L.T., Sokoloff, L. and Bunim, J.J.: Pathogene-
sis of rupture of extensor tendons at the wrist in rheumatoid arthritis.
Arthritis Rheum. 2:332, 1959.
7. Abernathy, P.J. and Dennyson, W.G.: Decompression of the extensor
tendons at the wrist in rheumatoid arthritis. J. Bone Joint Surg.
61B:64-68, 1979.
8. Nalebuff, E.A.: Surgical treatment of tendon rupture in the rheumatoid
hand. Surg. Clin. North Am. 49 (4):811, 1969.

Self-Evaluation Quiz

1. Secretan disease is caused by:

a) Dorsal hand infections
b) Rheumatoid arthritis
c) Recurrent trauma and hemorrhage
2. Dorsal and volar hand infections may present as swellings on
the dorsum.
a) True
b) False
Match the following forms of swelling to the appropriate
cause or definition:
ae 3, GOUt a) Bony swelling
_____4. Enchondroma b) Infection
____5. Lipoma c) Benign swelling
____6. Peritendinous fibrosis d) Defective lipid metabolism
_____7. Multiple xanthoma e) Defective uric metabolism
—____8. Edema f) Trauma
9. Which of the following circumsta nces in rheumatoid arth-
ritis lead to tendon rupture?
a) Lysosome release
b) Ulnar styloid dislocation
c) Excessive synovium
d) Synovitis
e) All of the above
10. Success of conservative therapy may be determined by:
a) Size of swelling
b) Pinch and grip strength
c) Wrist and finger motion
d) bandc
Answers on page 527.
 Wrist Problems

Bruce Butler, Jr., M.D.

Objective
The purpose of this discussion on rheumatoid arthritis
is to present methods of dealing with severe rheumatoid
changes in the wrist, alternatives, testing procedures and
diagnostic procedures for modes of management.
a

The rheumatoid wrist is a common problem faced at one

time or another by almost all orthopedic surgeons. There are
four distinct reasons for resorting to surgery in these patients.
The first and most prevalent is pain. This is a disease that hurts.
The second is to prevent functional loss. The third is to restore
function that has already been lost. Finally, we try to make the
patient’s hand look better — cosmesis plays a more important
role than most patients care to admit.
When faced with the rheumatoid wrist, where do we begin?
First of all, we postpone surgery for at least four months to see
if the problem will not respond to medication. We prefer to let
the internist or rheumatologist do the injecting, as it is
occasionally associated with tendon rupture.
When surgery is indicated, what are the common operations
performed? We do a synovectomy for pain and for prevention
of functional loss, i.e. to prevent tendon rupture. If a patient
has a swelling over the extensor pollicis longus as it goes by
Lister’s tubercle, we do a limited synovectomy. If tendons have
ruptured we do a synovectomy and a Darrach procedure. I
think the surgeon who does a synovectomy with ruptures but
does not take out the distal ulna has committed a serious crime.
For salvage we arthrodese and ““prosthesize,”’ because we
basically feel that, if possible, a patient should have one stable
ia, Va.
Bruce Butler, Jr., M.D., F.A.C.S., Hand Surgeon, Alexandr

373
 B. BUTLER, JR.
Ole

wrist and one that moves. However, some prostheses have to be

considered stable in that patients, once they have one, do not
want the other side fused; they want another prosthesis. The
only prosthesis we use is the Swanson. If there is doubt about
whether to fuse or to put in a prosthesis, we put a Steinman pin
across the wrist at zero degrees and let the patient live with a
pin in place for a month or two.
With the above as an introduction, let us examine some
specific problems:
Problem 1. A patient may present with just a small blob of
synovium. If it has been there for about four months, our
inclination is to go ahead and take it out through a very limited
approach.
Problem 2. With synovitis in a fairly badly damaged hand,
the approach we use is the Z or a lazy S. We use the Z more
often because the points can be realigned. In older people some
of the points will slough; so they must be closed with plenty of
room.
Problem 3. In a case where there is some invasion of the
tendons, the synovial seeds need to be cleaned out, as
sometimes the lumps catch in the retinaculum and cause the
extensor tendon to trigger.
Problem 4. In a case where the synovium has been removed
and the retinaculum is ready to swing under the tendon, the
retinaculum can be used as a new wrist capsule, a gliding
mechanism for the tendon and a checkrein for flexion. To me,
the worst wrists in rheumatoids are those that end up with
severe flexion; so I warn my patients ahead of time that I am
going to snug up the wrist so much that they are not going to be
able to flex completely ever again.
Problem 5. Sometimes you see a patient when the joint is
unimpaired, but all around it is a synovial mass. Here we do a
tenosynovectomy and a debridement, and then decide whether
to leave the ulna behind; generally we do not.
Problem 6. In some patients the extensor tendon may be
hanging off to the side. Very often the extensor tendon has
been so attenuated by the acutely flexed position that I do a
tendon transfer, actually moving the tendon out farther on the
carpus or whatever is left of the carpus distal to the prosthesis. I
do not do anything for the finger extensors since they seem to
WRIST PROBLEMS 375

accommodate nicely, but I worry about the wrist extensor; so I

always repair and shorten the radial extensors.
Problem 7. In a patient requiring a prosthesis, I would like
to test it before closing. I think that a range from 15° of
dorsiflexion to 20° of palmar flexion is sufficient motion for a
wrist prosthesis. A result is considered good if there is stability
along with some mobility, no pain, nice alignment and an
attractive arm. It is the stability of the Swanson prosthesis that
has led me to be satisfied with it, and it is the only one we use.
In connection with this, I would like to caution against
X-raying a prosthesis. After a few months you cannot even see
the prosthesis. The x-rays look terrible and the wrist moves
beautifully. My advice is this: if you do not have to x-ray the
patient, do not.
Problem 8. The last case I want to talk about illustrates
something extremely important about synovitis. A woman who
had been on steroids for five years for rehumatoid arthritis-was
pregnant. Interestingly, her rheumatoid disease did not improve
during pregnancy, which it should have done. Also, she had
carpal tunnel syndrome which did not improve after pregnancy.
We decided to operate to see what was wrong and found
tuberculosis. What needs to be remembered is this: not every
case of synovitis turns out to be a case of rheumatoid disease.

Self-Evaluation Quiz

1. If one considers wrist fusion (arthrodesis) in a rheumatoid

patient, one can stabilize the wrist temporarily as a trial of
fusion with:
a) Acast
b) A Steinman pin across the carpus between the first and
second metacarpals
c) A Kirschner wire
d) A Steinman pin across the wrist between the second and
third metacarpals
e) A plate and screws across the wrist
2. Acarpectomy is part of which following procedure:
a) Tenodesis
b) Arthrodesis
c) Prosthesis
d) Synovectomy
376 B. BUTLER, JR.

3. X-rays of which of the following procedures do not help

much in evaluating a problem several months after the
procedure:
a) Arthrodesis
b) Prosthesis
c) Tenodesis
d) Synovectomy
e) Darrach procedure

Answers on page 527.

 Panel:
General Hand Problems
 Discussion:
General Hand Problems

Moderator: Grady S. Clinkscales, M.D.

Panelists: | Norman J. Cowen, M.D.

Avrum I. Fromison, M.D.
Edward J. Nalebuff, M.D.

Moderator: Z-plasties and incisions across the rheumatoid

wrist have often been made. Why would you not ever do a
shallow S-shaped dorsal wrist incision in order to prevent skin
sloughing, such as with the Z-plasty incision?
Dr. Cowen: I am hesitant to do Z-plasties on the dorsum of
the rheumatoid wrist. I worry about the circulation in this area.
I tend to use a very gentle S-shaped incision. Sometimes I use a
longitudinal incision to avoid this problem entirely.
Moderator: That is a good point. The dorsal skin in a
rheumatoid patient is particularly thin, very friable and does
have a tendency to slough. Perhaps Dr. Nalebuff would also like
to comment.
Dr. Nalebuff: That is the one place where I think a straight
incision is indicated. In rheumatoid surgery, you are dealing
with people who have a vasculitis; they are not like anybody
else. Once you start making curved incisions, you are asking for
a skin slough. So most of us who do a lot of this type of surgery
use straight incisions for wrist fusions, wrist arthroplasties and
dorsal tenosynovectomies.
, a
Moderator: When a dorsal wrist ganglion is excised
the stalk
window in the capsule is made in order to be sure that
window is
of the capsule has been adequately excised. If a small
is taken, there
taken there is no problem; but if a large window
of scaphoid subluxation or rotatio n
may be a problem
postoperatively. Has anyone seen this occur?

379
380 DISCUSSION

Dr. Nalebuff: I have seen a couple of them. I think the

problem occurs when the surgeon does not distinguish the
intercarpal (scapholunate) ligament and the dorsal capsular
structure of the wrist. If you are going to take out a ganglion,
you do not want to remove this intercarpal ligament. It does
happen when people are careless, but it should not happen.
Moderator: So it does occur. I have seen one also.
Dr. Nalebuff, in a silicone arthroplasty of the thumb
metacarpophalangeal joint, the joint is not always a stable one
after implant. What are your methods for overcoming this?
Dr. Nalebuff: Yes, that is true. That is a good question. I am
sorry I did not comment on that earlier. It should be treated
completely differently from the arthroplasty of the other digits
— in other words, in the postoperative splinting and in the
suturing of the capsule, everything is done to make it tight. You
are not in any way trying to get a lot of motion when you do ani
arthroplasty at the metacarpophalangeal level of the thumb. As
a matter of fact, you are probably going to get more motion
than you want. So you snug up the capsule, particularly
dorsally and on the ulnar side. Then you splint this with a cast
or splint for probably four or five weeks. In spite of this, they
seem to get a fair amount of motion. In brief, you have to treat
it more for stability, leaving some motion, and try to just relieve
pain.
Moderator: Dr. Nalebuff, in the type 2 swan-neck deformi-
ty, when you are doing a metacarpophalangeal silicone joint
arthroplasty and you take out some of the ulnar sagittal fibers
of the hood, do you also release completely the ulnar intrinsics
when there is also ulnar deviation of the fingers?
Dr. Nalebuff: In metacarpophalangeal arthroplasties we
always release the ulnar intrinsic as part of the procedure. The
ulnar intrinsic is the cause of ulnar deviation. As part of our
exposure we release the sagittal fibers of the extensor mecha-
nism and we remove the intrinsic as well. Not only do we incise
it, but we take out a portion of it because it tends to grow back.
If that is not enough to get the finger over freely, we will then
actually incise or excise the ulnar collateral ligament as well.
Moderator: That is a good point because it brings out the
fact that you have to de more than an isolated surgical
GENERAL HAND PROBLEMS 381

procedure if there are other deformities. So taking out the

sagittal band may not be enough by itself, and you have to
combine that with additional releases to correct the deformity.
In discussing rheumatoid problems another question arises.
In the swan-neck deformity, one way to gain flexion at the
proximal interphalangeal joint is to hold it in flexion, and at
times with pins inserted across the joint. Do the other members
of the panel immobilize in the flexed position with pins? Has
there been any problem of sloughing of the dorsal skin?
Comment: The answer is yes to all three questions. We
manipulate joints into flexion not only in rheumatoids but also
in patients with posttraumatic stiffness. If it is done for a
couple of weeks, it is perfectly safe. You may have to do a skin
release. We should just stop for a second and find out how good
an idea a skin release is and how rarely we need skin grafting.
How completely the field of hand surgery has changed since the
introduction of the technique of McCash. Less and less do we
have to do split-thickness skin grafts.
Moderator: Dr. Cowen, do you ever use pins and do you
ever see skin sloughs over the dorsum of the proximal
interphalangeal joints in the rheumatoid?
Dr. Cowen: Yes, I do.
Moderator: Dr. Froimson, do you?
Dr. Froimson: There are probably still people who dislike
the word “‘manipulation.”’ The idea is that if you manipulate a
joint, it is going to hurt so much that the patient will end up
being worse than when you started. That may be true if you
manipulate a joint and set it free, because it does hurt. The
patient ends up putting it back in the protected position of
extension and does not move it. But if you manipulate a joint
and then put it in flexion and hold it with a Kirschner wire so
that it does not move, it does not hurt. What you are
accomplishing is the stretching of everything that can stand
the
stretching. The extensor mechanism can be stretched and
can be stretched. They do not have to be
collateral ligaments
are held in flexion for a period of ten days to three
cut. If they
cannot
weeks, they will stretch out. The only structure that
stretched is the skin. When you take the pins out,
tolerate being
you have
you then will be very pleasantly surprised to see that
picked up 80° or 90° of motion. So I think the idea that
382 DISCUSSION

manipulation is a bad thing is completely wrong, if you do it in

the right context. You have to eliminate pain by keeping it still
for a while.
Dr. Nalebuff: I agree with what Dr. Froimson has said;
however, these things are not just true in rheumatoid arthritis
but will work just as well in posttraumatic situations.
Moderator: The second part of the question is, do you think
that pins inserted dorsally into the proximal phalanx produce
excessive tension on the skin while the fingers are held in
flexion? In other words, does this dorsal position of the pin
contribute to skin slough? If so, do you think that inserting the
pins in an oblique direction, that is, from the side of the finger,
would have any lesser effect on producing a skin slough?
Dr. Froimson: That is an interesting point, but I do not
think this is the problem. Even if you hold the PIP joint in
flexion with tape and no pin at all, the skin is temporarily
shortened. There is no skin loss. It is reminiscent of the
principle of McCash when you make an incision in the palm
while releasing a Dupuytren’s contraction and leave the wound
open. The wound does not heal because new skin is formed. All
that happens is that granulation takes the old skin and stretches
it back out. It heals with a normal surgical scar. The same thing
applies here. There is no loss of skin; it is contracted. The skin
will gradually come back together and stretch out. So I think
you should hold them in flexion. Putting the wire in from the
side would not change that, because it happens when you use
just tape.
Dr. Cowen: Would you use the same incision which gives
him the extra skin in a nonrheumatoid patient?
Dr. Froimson: Yes, I do. I have done it in patients after
tenolysis following fracture healing. I have not cut a collateral
ligament of the proximal interphalangeal joint in five years. I
have not operated on anybody with a stiff finger and released
the collateral ligament, because the collateral ligament is
something that can be stretched. The extensor mechanism can
be released either by manipulation or by lateral band release.
The collateral ligament will respond to being held down. It is
only the skin that will not take stretching.
Dr. Cowen: In a nonrheumatoid patient, I worry about the
skin. I know I am going to have trouble with it. Recently, in a
GENERAL HAND PROBLEMS 383

few cases, I have opened the dorsum with an exaggerated zigzag

incision and then treated each triangular flap on the side as a
V-Y flap advancement. This produces more skin in the
longitudinal direction. It has worked nicely so far. I wonder if
anyone else has tried this and what their experience has been.
Comment: I think there is more than one way to get more
skin dorsally, at least temporally. The thing you must remember
is not to leave it open over the joint, because the central slip
attachment will slough.
Moderator: In the rheumatoid thumb the metacarpo-
phalangeal joint frequently subluxes volarward due to stretched
capsule and collateral ligaments. Do you feel, Dr. Nalebuff, that
the dorsal reconstruction of the capsule, along with a transfer of
the, extensor pollicis longus, provides enough stability to
prevent the subluxation?
Dr. Nalebuff: Only in those situations in which there is full
passive correctability. You have to come up absolutely easy.
Therefore, the indications for that procedure are few and far
between. The indications suddenly increase once you start
thinking about putting a prosthesis in place, because with a
prosthesis you have a joint that theoretically you can bring into
full extension passively without pressure. I went through a
period in which I did a number of EPL reroutings, but the
indications are not so common. It is much better to fuse the
joint. If you put in a prosthesis and see that it is going to fall
down, then start thinking about how to get more power. This is
one way to get more power.
Moderator: I think this is the important point: even though
there is a ruptured extensor pollicis longus tendon, simple
reefing of the dorsal capsule may not be enough to realign the
joint. You must have a good joint to start with, and you must
be able to passively correct the joint in order for the procedure
to do what you expect it to do.
Dr. Nalebuff, in the type 4 swan-neck deformity, after you
have inserted a silicone prosthesis at the proximal inter-
phalangeal joint, you stress the importance of an intact flexor
mechanism. You make a palmar incision and tug on each of the
flexor tendons to see if they are intact and will fully flex the
the
proximal interphalangeal joint after you have inserted
find in the flexor tendon
prosthesis. What do you expect to
384 DISCUSSION

mechanism that will not allow the proximal interphalangeal

joint to work passively?
Dr. Nalebuff: The tendons get stuck to each other. Let us
say that we are doing a metacarpophalangeal arthroplasty at the
same time. Through the metacarpophalangeal arthroplasty
incision we will cut the volar plate, reach down and pull the
flexor tendons through the metacarpophalangeal joint and see if
the finger will berd. That will save turning the palm over to
check it. But let us assume you are just talking about the
proximal interphalangeal joint. I shall make a transverse incision
in the palm, spread everything out, open the sheath and pull on
the tendon. Usually, I pull on both tendons together to see
what will happen. If the finger does not move, then I go into
the sheath to the superficialis and pull on it separately. If it
does not move very much, then I pull on the profundus tendon.
If this does not move very much, then I put a tendon hook in
and pull the two tendons in different directions. Suddenly the
finger comes down. What you usually have is an adhesion
between the two tendons. Occasionally there will be large
nodules, which one should pick up preoperatively. Most of the
time, if the finger has not moved in six months to two years,
the tendons have probably become stuck to each other. It is not
the same as in trauma where mere tugging on them will free
them up.
Moderator: Dr. Cowen, how do you treat volar finger
contractures due to necrosis of skin and fat following trauma.
What would be your method of replacing skin and releasing the
contracture at the proximal interphalangeal joint?
Dr. Cowen: You have to be prepared for contracture at
every single layer, from the skin down to the bone. The tendon
sheath may be adhered to the tendon. The tendons themselves
may be damaged and adherent. The collateral ligaments will be
contracted. The volar plate may be scarred. There may be
scarring within the joint. So I think you have to see what is
there and then go layer by layer.
Moderator: Let me rephrase the question in order to
identify more particularly the set of circumstances. It has been
an open wound that has granulated in. The scar has adhered
volarly to the underlying flexor tendons. The neurovascular
bundles are intact. The finger is in 90° of flexion at the
GENERAL HAND PROBLEMS 385

proximal interphalangeal joint. You attempt passive extension

of this joint and find that it is a painless maneuver, which
indicates that the contracture is probably in the soft tissues
around the joint rather than within the joint. What do you do
to release this skin contracture? What do you do for skin
coverage? What kind of graft or flap would you use?
Dr. Cowen: I usually will open that on the volar side with
what I call a wagon wheel type of incision. This is a technique I
learned from Dr. Robert Carroll of New York. It is like an X.
After I have made the incision and undermined the edges, the
finger can then be extended. The incisions will open up into
two diamond-shaped defects, one proximal and one distal. They
will be separated by two flaps based on the sides that will just
tough each other in the midline. Then on each end of these two
flaps will be a diamond-shaped defect, which I fill in with a
split-thickness or full-thickness skin graft. This technique is
similar to releasing the contracted skin with a transverse
incision. A transverse incision, which goes from the midlateral
line to the midmedial line, would form a single diamond-shaped
defect when the finger is extended. The wagon wheel technique
is comparable to using two parallel, transverse incisions close to
each other and ending up with two diamond defects. Once the
skin is released I would free up the tendon sheath and check for
tendon adhesions. If the joint is still stuck, I would take the
tendon to the side and remove the accessory collateral ligament
on each side of the volar plate. This usually releases the joint,
but if not, I would then release the volar plate itself. One must
go step by step and do whatever is necessary from superficial to
deep to bring the finger out into full extension.
 a

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Annual Washington Review Course
in Hand Surgery
 Upper Extremity Prosthetics
Prescription Writing, Sources of Power,
and Harnessing

Charles H. Epps, Jr., M.D.

Objectives
s The physician who only occasionally is faced with a
patient needing an upper extremity prosthesis may find
writing the prescription difficult. This discussion will offer
a system (deficit replacement) to prescribe prosthetic
devices for absent anatomical segments. In addition, basic
data concerning power sources and harnessing will be
discussed.

There is available today an extensive arnamentarium of

prosthetic components from which the clinician may select
those that seem most appropriate for the particular patient. The
writing of the prescription is often difficult for the physician
who only occasionally sees a prosthetic patient, but can be a
relatively easy task if simple procedures are followed. If one
conceives the extremity, either upper or lower, as a modular
structure, then the prescription simply describes the com-
ponents necessary to replace the missing unit sections (Table 1).
Finally, a means of activating the device is selected and all
special and nonstandard features are indicated. The prescription
replaces only the missing portion of the extremity; hence, the
system I wish to suggest is called deficit replacement.

Ortho-
Charles H. Epps, Jr., M.D., Professor and Chief, Division of
Surgery, Howard Universit y Medical Center; Clinic Chief, Juvenile
paedic
Amputee Clinic, General Hospital, Washington, D.C.

389
 C. H. EPPS, JR.
390

Table 1. Prosthetic Components

Hand Wrist Forearm Elbow Upper Arm Shoulder

Terminal device ‘Wrist Forearm Elbow Upper arm Shoulder

or partial unit shell unit shell unit
hand, i.e. or BE or
opposition post socket AE socket Shoulder

Muenster cap socket

for very One e
Rhort quarter
socket

Harnessing and Power Sources

The harness serves a multifaceted purpose, serving as an

attachment for the control cable, suspension in some cases, and
usually providing a means for elbow lock and unlock control.
The sources of power utilized to operate the prosthesis can be
either external power (electrical or carbon dioxide) or the
patient’s body, the so-called body-powered prosthesis.
In the body-powered below-elbow (BE) and above-elbow
(AE) prostheses, the classic harness system is the figure of eight,
which may utilize the Northwestern ring or simply be stitched
where the straps cross in the back. The figure of nine harness is
used with the Muenster prosthesis in most cases. The saddle
harness or other special modifications may be necessary for
individual patients performing heavy work.
For both the BE and AE amputee, the most common source
of power is humeral flexion. In the BE arm, this motion results
in operation of the terminal device. In the AE arm, it
accomplishes either terminal device operation or forearm lift
(depending on whether the elbow unit is locked or unlocked. At
the shoulder disarticulation level, the control cable can be
attached to a thigh cuff, peroneal strap or a waist strap. Any of
these would utilize shoulder elevation. A chest strap utilizing
chest expansion combined with scapula abduction is another
means of obtaining power at the shoulder disarticulation level
of deficit. However, the latter techniques are tremendously
energy-consuming.
Biceps cineplasty is another means of powering the below-
elbow amputee, which was popular after World War II. This
procedure is not recommended for children. A technique
UPPER EXTREMITY PROSTHETICS 391

utilizing pectoral cineplasty has also been described. The

Krukenberg operation is also useful for the bilateral blind
amputee and is used more frequently in Europe than in the
United States.
External power enjoys its widest application at the below-
elbow level. The Otto Bock System is commercially available
and the myoelectric controls are easily managed by patients.
Rolf Sorbye is gaining extensive experience in fitting young
children, under the age of 6 years, with a myoelectric system.
His results have been impressive.
We have used external power in most instances for our
young patients with severe congenital deficiencies, such as
amelia and phocemelia. The Michigan Electric Hook, the
Ontario Crippled Children’s Center Electric Elbow (OCCC) and
the New York University Electric Elbow are devices most often
used in our clinic. We have been successful in making a hybrid
arm consisting of the Michigan Hook and either the OCCC or
the NYU electric elbow. All except the NYU unit are
commercially available.

Components

Terminal Device. The purpose of the assembled components

is to position the terminal device best to perform its prehensive
function. There is a variety of terminal devices, beginning with
the 12 P hook. This is used for the infant and is plastic-covered,
making the fingers soft and easily cleaned. One may choose the
passive infant unit as the initial terminal device. Naturally, the
infant hook is not activated. The hooks are graduated in size
and are constructed of aluminum, designated by a number and
X, while an identical series is available in steel for those adults
performing tasks requiring strength and hardness of the terminal
device. Special modifications such as the farmer’s hook are
available.
Partial hands are usually cosmetic and may replace portions
of a finger(s) or a substantial portion of the hand. Usually, these
devices are cosmetic and add little or no function. The
opposition post, while uncosmetic, may be very functional,
providing usually pinch and grasp functions.
Prosthetic hands may be either cosmetic or functional. The
nonfunctional hands are lightweight and, when covered with a
392 C. H. EPPS, JR.

cosmetic glove properly matched, give an excellent cosmetic

effect. Most functional hands have a mechanism that opposes
the thumb against the index and long finger tip and, when
covered with a cosmetic glove, also have good cosmetic effect.
Dorrance lists four sizes which are widely used, although
additional models are available from the manufacturers.
Wrist Units. These devices attach the terminal device to the
forearm segment or the socket as indicated. They may be round
or oval and are sized. A wrist-flexion unit should be applied at
least to the dominant side in a bilateral amputee. The
quick-disc onnect unit is helpful to the patient who uses a hook
and a functional hand interchangeably.
Forearm Sheil. This section is made of plastic laminate. In
the below-elbow cases, the shell becomes the socket. The
Muenster is preferred for the very short below-elbow amputa-
tion level. The split-socket configuration is an alternate fitting
for this level. In the very young a preflexed socket is used.
Elbow Unit. If the patient has an elbow disarticulation or
higher level, an elbow unit is needed. The hinges are outside if
the stump is long but if there is approximately a 4-inch
discrepancy, an inside locking mechanism (better comesis) can
be used. The lock and unlock mechanism is activated by a
portion of the harness, a manual lock or, in the case of the
shoulder disarticulation, a nudge control.
Upper Arm. This segment may serve as the unit connecting
the elbow and shoulder joints or, in the case of the above-
elbow, constitute the socket. In the very short AE the proximal
socket may be modified to enhance suspension.
Shoulder Cap. This socket is used in the shoulder disarticu-
lation level or forequarter patient. Suspension is often difficult
and one often has to make custom modifications.
Shoulder Unit. Patients with the shoulder disarticulation or
forequarter level may require a shoulder joint. This may be a
universal joint or motion may be limited to two planes.
Occasionally in the young child we use a simple hinge joint.
Use of Plastic Materials. The forearm and upper arm
segments and the sockets are generally plastic laminate. This
material has the advantage of being lightweight and easily
cleaned by wiping with a damp cloth. The laminate may be
nonporous or porous for hot climates or fenestrated by multiple
UPPER EXTREMITY PROSTHETICS 393

holes to promote heat regulation without sacrificing too much

strength.

Summary

The writing of a prescription for an upper extremity

prosthesis can be simplified if one conceptualizes the absent
parts in terms of bodily joints and segments and replaces these
with appropriate components (deficit replacement). Then one
applies a harness properly powering the terminal device. Special
modifications are made as indicated.

Self-Evaluation Quiz

1. The terminal device in the initial prosthetic device for an

infant is:
a) Steel hook
b) 12 P hook
c) Otto Bock functional hand
d) Michigan Electric Hook
2. Which one oft the following is not a source of body power
for prostheses?
a) Forearm flexion
b) Scapular abduction
c) Neck lateral bend
d) Chest expansion
3. Myoelectric prostheses may be successfully fitted to chil-
dren under the age of 6 years:
a) True
b) False
4. The patient with a shoulder disarticulation level usually has
as much function with the prosthesis as the patient with
elbow disarticulation level.
a) True
b) False
5. The usual harness for the Muenster prosthesis is which of
the following?
a) Figure of nine
b) Figure of eight
c) Figure of eight with saddle addition
 G2 HO ERPS) IR:
394

The proper indication for the Muenster prosthesis is which

level?
a) Wrist disarticulation
b) Medium length below-elbow
c) Very short below-elbow
d) Elbow disarticulation
Which modifications are helpful to a farmer with a standard
below-elbow?
a) Saddle harness
Di meE2 hook
c) Farmer’s hook
d) Figure of nine harness
A bilateral below-elbow amputee would find which device
helpful (conventional below-elbow fitting)?
a) Nudge control
b) Steel hook
c) Wrist flexion unit on dominant side
d) Figure of nine harness
Biceps cineplasty is recommended for infants and children.
a) True
b) False
AMG, Sockets of plastic are suitable for adults performing manual
labor or strenuous activities.
a) True
b) False

Answers on page 527.

 The Treatment of Nerve Injuries
F. William Bora, Jr., M.D.

Objective
The purpose of this paper is to compare the results and
effectiveness of suture techniques in management of nerve
lacerations.

Epineurial vs. Perineurial Suture

Most nerve lacerations are clean and proximal to their

terminal fascicular divisions. Two of the most important
decisions to be made by the surgeon treating acute nerve
lacerations are how and when to suture these multifasicular
injuries. Authors have reported that epineurial suture is unre-
liable in restoring accurate fascicular anatomy after nerve
laceration, and perineurial sutures give more satisfactory results
in both clinical and experimental situations [1]. Because the
use of perineurial suture is more difficult technically, more
time-consuming and, if not properly executed, creates more
intraneurial scar which is more directly obstructive to axon
regrowth than is the epineurial suture, accurate and repro-
ducible methods of study are needed to compare the return of
nerve function after nerve repair by the two techniques. Exact
biochemical methods were used in this study to compare the
extent of nerve regeneration following epineurial, perineurial
and a combination of the two suture repairs in rabbits in early
and late situations (Figs. 1-3).

Materials and Methods

Sixty adult male Dutch Belted rabbits were anesthetized
with spinal anesthesia. One sciatic nerve was transected midway
of the
F. William Bora, Jr., M.D., Department of Orthopedics, Hospital
University of Philadelph ia, Philadelph ia, Pa.

395
396 F. W. BORA, JR.

FIG. 2. Drawing of perineural repair. (Reprinted from Bora [3].)

TREATMENT OF NERVE INJURIES 397

FIG. 3. Drawing of combined epineural and perineural repair. (Reprinted

from Bora, F.W., Jr.: J. Hand Surg. 1 (2):138-143, 1976.)

between the sciatic notch and the knee in each rabbit. The 60
rabbits were divided into six groups of ten rabbits per group,
and the lacerated nerve was repaired by placement of two 7-0
silk sutures and studied by the following methods: (1) the
sciatic nerve neuroma immediately distal to the suture (Fig. 4),
and (2) the myelin content in the posterior tibial nerve (Fig. 5).
These specimens were studied by the following methods to
evaluate the amount of scar caused by each technique, as well as
the return of nerve function after the various suture methods
used in this study: (1) collagen in the sciatic neuroma immedi-
ately distal to the suture (by hydroxyproline assay) [2];
(2) collagen in the posterior tibial nerve (by hydroxyproline
assay) [2]; and (3) biochemical assay of myelin content of the
posterior tibial nerve (myelin was osilated by sucrose by density
gradient ultracentrifugation [3] and quantitated by sterol [4],
phospholipid [5], sulfatide [6] and protein assays [7].

Results
No functional return of muscle strength was observed below
-
the knee on the operated side in the various groups. Biochem
of collage n in
ical data were used to compare the percentage
a immedi-
total protein [8] found in the sciatic nerve neurom
ately distal to the suture and in the posterior tibial nerve.
398 F. W. BORA, JR.

_ Neuroma
F (collagen)

FIG. 4. Drawing of sciatic nerve neuroma. (Reprinted from Bora, F.W.,

Jr,: J. Hand Surg. 1 (2):138-143, 1976.)
TREATMENT OF NERVE INJURIES 399

Bora, PeeWee te:

FIG. 5. Drawing of posterior tibial nerve. (Reprinted from
J. Hand Surg. 1 (2):138-143, 1976.)
400 F. W. BORA, JR.

Myelin production is an index of axon growth and

maturation and was used in this study to determine nerve
regeneration at death. Biochemical data were again used to
compare the percentage of normal myelin in the operated nerve
in various suture-technique groups studied. Myelin content was
estimated as the sum of cholesterol, phospholipid, sulfatide and
protein [9-12]. Cerebroside was not assayed.
The myelin content of injured nerves increases as axons
penetrate the distal segment and mature [13, 14]. A sensitive,
quantitative method to determine the extent of nerve regenera-
tion after laceration and suture is by the assay of myelin in the
distal segment. The most significant finding in this study was
that 60.0% of normal myelin production was found in the
posterior tibial nerve in nerve lacerations repaired by immediate
epineurial suture, compared to 23.8% in the perineurial im-
mediate group and less in the delayed groups. This suggests to
the operating surgeon that immediate epineurial repair is the
best treatment for the clean, multifascicular laceration in
clinical practice.
Most of the collagen in peripheral nerves is in the
epineurium, separated from the myelinated and unmyelinated
axons by the perineurium, a multilamellar sheath of mesothelial
cell [15]. The well-defined normal fascicular pattern is lost at
the site of nerve transection; during nerve regeneration, multiple
slender ‘‘pseudofascicles’”’ form in the anastomotic zone, each
surrounded by a slender perineural layer, all within a much-
thickened epineurium [16]. Collagen content of the anasto-
motic zone, as judged by hydroxyproline assay, increases
progressively following nerve section and repair and may reach
more than 60% of total protein, particularly when epineurial
suturing techniques are used [4, 14]. It is likely that the scar
induced by epineurial sutures is predominantly in the periphery
of the nerve and not so much an impediment to penetration of
axonal sprouts as the perineurial scar induced by fascicular
suturing. It is probably for this reason that the rate of nerve
regeneration in rabbits after immediate epineurial repair of a
sectioned sciatic nerve is greater than that with immediate
perineurial repair.
Morphological observations by Holmes, Saunders and
Young [17, 18] suggested that, after nerve transection, the
TREATMENT OF NERVE INJURIES 401

endoneurial Schwann cell tubes in the distal nerve segment

become progressively constricted by deposition of endoneurial
collagen and that this endoneurial fibrosis results in a perma-
nent reduction in the diameter attained by regenerating axons.
Abercrombie and Johnson [19, 20] found that the collagen
content of the distal nerve segment of transected rabbit sciatic
nerve increases linearly for more than a year after the injury and
concluded that the entire distal segment was involved. We have
confirmed that collagen scar formation does occur in the distal
stump of transected nerves, whether or not the nerves are
repaired, but we have found that that scar is confined to the
initial few millimeters below the injury and does not extend
into the remainder of the distal nerve segment. It has been
suggested that one of the reasons for failure to recover full
muscle power after nerve transection and regeneration is
progressive fibrosis of denervated muscle so that the mechanical
properties of the muscle are impaired permanently despite
reinnervation. Histologic observations of denervated muscle
confirm that the proportion of the muscle cross section taken
up by fibrous tissue is increased, but we have found that the
total collagen content in triceps surae muscle after sciatic nerve
transection in rats does not increase even a year following the
denervation. Rather, collagen content remains constant while
the muscle fibers atrophy (Pleasure and Bora, unpublished
data). These observations indicate that collagen scar formation
after nerve transection is confined to the immediate region of
the traumatic zone, and suggest that measures limiting scar in
this region might be successful in improving the prognosis of
patients with nerve injuries.
In clinical practice, immediate repair of the nerve injury
often is not possible owing to contamination of the wound and
associated injuries of other tissues. Delayed suture must be done
then and is best done by specialized personnel with micro-
surgical instrumentation. At this time we feel that better
functional results are found most consistently after epineurial
suture is used to repair clean multifascicular nerve injuries.
of
Perineurial suture has the advantage of the surgical matching
method, combined with the local control of
fascicles and this
may become a more satisfactor y method to
intraneurial scar,
repair nerve lacerations in the future.
402 F. W. BORA, JR.

This experimental study was designed to compare the

effectiveness of epineurial (Fig. 1), perineurial (Fig. 2) and
combined epineurial and perineurial suture (Fig. 3) after
laceration of the sciatic nerve in rabbits by biochemical
determinations in both immediate and delayed repairs. Rela-
tively more myelin was found in the immediate epineurial
group, which suggests that nerve regeneration was most rapid in
this group. Additional experiments are needed to evaluate
end-organ reinnervation, which is another criterion for evalu-
ating the best method of nerve suture in clinical situations.

Recommended Treatment for Nerve Suture

Judgment
Factors to be considered as to whether a nerve laceration
should be repaired primarily or secondarily are:
1. Circumstances of the injury. (A knife wound in a
kitchen favors primary repair; a wound in a machine
shop favors secondary repair.)
2. Time elapsed between the injury and treatment. (One
hour favors primary suture; 24 hours favors secondary
repair.)
38. Character of the wound. (A clean wound favors primary
repair; a dirty wound favors secondary repair.)
4, Other injuries. (A cut involving skin, nerve and one or
two tendons favors primary suture; multiple injuries,
such as head or abdomen or multiple tendon lacerations,
favor secondary nerve repair.)
5. The leisure of the surgeon. (A well-rested operator
performs a more exact suture, and the ultimate func-
tional result of a nerve repair reflects the technical
exactness of the method of suture.)
The examples cited above are obviously at the extremes of
the scale of each consideration, and when they approach the
middle of the scale, as they frequently do, each factor must be
evaluated not only in itself but in relation to all the other
factors as presented. In general, open nerve lacerations should
be repaired primarily, and closed nerve injuries observed until it
has been determined by repeated clinical examinations and
electrical diagnostic studies that a period of time has elapsed in
TREATMENT OF NERVE INJURIES 403

which one would expect an end-organ reinnervation; if recovery

has not taken place as expected, secondary surgery should be
performed.

Timing
Suturing a nerve primarily subjects the patient to only one
operation and one hospitalization. Primary nerve suture lessens
the reinnervation time of muscle and sensory receptor end-
organs. If the acute injury is complicated by multiple injuries or
possible infection of the wound, secondary repair is the
treatment of choice. Factors favoring secondary suture are as
follows: (1)The epineurium is thicker, enabling the surgeon to
place sutures more accurately, and the thicker epineurium holds
the suture more firmly, making tying easier. (2) The intraneurial
fibro$is which occurs at the cut ends after nerve laceration can
be more easily assessed at secondary suturing, making trimming
of the nerve ends easier. Based on observations made in
evaluating the functional results in clinical cases, as well as on
data from experimental situations, it is clear that the prime
objective of a surgeon treating a nerve laceration is to suture the
cut as soon as it is conveniently possible.

Technique
Acute skin lacerations can usually be incorporated into
physiologic incisions which make nerve exposure suitable for
mobilization and suture. After skin and subcutaneous dissec-
tion, normal nerve should be identified proximal and distal to
the neuroma, after which the neuroma, including some of the
surrounding scar tissue, is isolated by sharp dissection. With this
technique, intact fascicles may be preserved and only the
injured fascicles within the neuroma are isolated and sutured.
Acute lacerations have blood clots in various degrees of
maturation between the cut ends, rather than the tough fibrous
tissue which is present in late nerve repair situations. After the
neuroma or injured nerve ends are isolated, a #11 scalpel blade
is used to trim the nerve to normal fascicular tissue. A
moistened tongue blade is placed behind the nerve to protect
other structures and to provide cutting resistance as the nerve
ends are freshened.
Magnification is helpful in aligning rotation, in matching
fascicles and in the placement and tying of sutures. The
404 F. W. BORA, JR.

microscope is used in most upper extremity repairs; however,

loops are used for epineurial repairs of large proximal nerves,
such as the sciatic and the brachial plexus. Size 10-0 monofila-
ment nylon is recommended for nerve suture, but a larger
suture size may be utilized if more strength is needed to bring
nerve ends together. Many cases require two or three 6-0 or 7-0
nylon sutures to hold the nerve ends together and, after tension
is overcome, smaller 10-0 sutures are used to approximate the
lacerated epineurial edges. Fine jeweler forceps, a nonlocking-
eye needle holder and sharp nerve scissors are especially helpful
in this delicate surgery.
Anatomy which assists the surgeon in fascicular orientation
is the vascular markings on the outside of the nerve and the size
of the fascicles on the proximal and distal faces of the lacerated
nerve edges, especially if the cut ends have not been trimmed. If
an acute laceration is clean, one can remove the blood clots
between the fascicles, and the fascicles and the epineurium,
thereby eliminating all trimming. This technique increases the
chance of good fascicular matching because axons do change
places with the peripheral nerve as they run from the shoulder
to the fingertip, and trimming changes the fascicular patterns at
the cut ends. Fibrous tissue is provoked by each nerve suture
which obstructs axon sprouting and maturation; therefore, a
minimum number of stitches is recommended for nerve end
repairs. Fascicular sutures require at least one suture per fascicle
and, in some cases, two or three. Judgment regarding the
number of sutures depends upon how each fascicle lies after the
placement of each suture.

Fascicular Suture
Epineurial sutures are used in most nerve lacerations, but
the fascicular technique is used when the nerve is cut where it
divides into its terminal fascicular branches. Fascicular suture is
used when the median nerve is cut at the level of the carpal
canal where several (four to seven) fascicles must be sutured
back to the stem median nerve. In such cases, the epineurium is
removed proximally and the fascicles identified so that specific
fascicles are sutured individually. The ulnar nerve, when cut
proximal to the wrist, is easily divided into two divisions, the
main ulnar and the dorsal sensory to the hand, and the two
TREATMENT OF NERVE INJURIES 405

nerves are repaired by a perineurial stitch. Lacerated radial

nerves at the elbow, and lacerations of the common digital
nerve where it divides into its proper branches at the base of the
finger, are also sutured by the fascicular method. Sutured
main-trunk lacerations are immobilized for six weeks and digital
nerve cuts with little tension are held for three weeks.
Nerve function is compromised by injuries other than
transection. Bullet wounds, needle injections and localized
pressure on the skin produce hemorrhage and ultimate scarring
in and around the nerve in the area of injury. Patients with such
injuries, who have altered nerve function, should be followed
carefully by repeated clinical examinations and electrical
diagnostic testing and, if the nerve function deteriorates or does
not return to an acceptable level within a reasonable period of
time,* are candidates for surgical release. Neurolysis, using
magnification and microsurgical techniques, may be helpful in
such cases.

References

1. Pleasure, D.E., Mishler, K. and Engle, W.K.: Axoplasmic transport of

proteins in experimental neuropathies. Science 166:524, 1969.
2. Grafstein B., McEwen, B.S. and Shelandski, M.L.: Axonal transport of
neurotublin protein. Nature 227:289, 1970.
3. Bora, F.W.: Peripheral nerve repair in cats: The fascicular stitch. J.
Bone Joint Surg. 49A:659, 1967.
4. Sunderland, S.: Nerves and Nerve Injuries. Edinburgh-London:E. & S.
Livingstone, 1968.
5. Pleasure, D.E. and Towfighi, J.: Onion bulb neuropathies. Arch.
Neurol. 26:289-301, 1972.
6. Prockop, D. and Udenfriend, S.: A specific method for the analysis of
hydroxyproline in tissues and urine. Ann. Biochem. 1:228, 1960.
7. Norton, W.: Isolation of myelin from nerve tissue. Methods Enzymol.
381A:435, 1974.
8. Rudel, L. and Morris, M.: Determination of cholesterol using
0-phthaldehyde. J. Lipid Res. 14:354, 1973.
9. Kates, M.: In Techniques of Lipidology. Amsterdam:Elsevier Publish-
ing Company, 1972, pp. 424-425.
for quanti-
10. Kean, E.: Rapid, sensitive spectrophotometric method
tative determination of sulfatides. J. Lipid Res. 9:319, 1968.
ent with
11. Lowry, O., Rosebrough, N., Farr, A. et al: Protein measurem
the folin phenol reagent. J. Biol. Chem. 193:265, 1951.
 F. W. BORA, JR.
406

WA, Spies, J.: Colorimetric procedures for amino acids. Methods Enzymol.
SAMS, WOT
13. Schroder, J.: Altered ratio between axon diameter and myelin sheath
thickness in regenerating nerves. Brain Res. 45:49, 1972.
14. Pleasure, D., Bora, F.W., Jr., Lane, J. et al: Regeneration after nerve
transection: Effect of inhibition of collagen synthesis. Exp. Neurol.
45:72, 1974.
15. Shanthaveerappa, T. and Bourne, G.: Perineurial epithelium: A new
concept of its role in the integrity of the peripheral nervous system.
Science 154:1464, 1966.
16. Ballantyne, J.P., Jr. and Campbell, M.: Electrophysiological study
after surgical repair of sectioned human peripheral nerves. J. Neurol.
Neurosurg. Psychiatry 36:797, 1973.
Le Holmes, W. and Young, Y.: Nerve regeneration after immediate and
delayed suture. J. Anat. 77:63, 1942.
‘ees Saunders, F. and Young, Y.: The role of the peripheral stump in the
control of fiber diameter in regenerating nerves. J. Physiol. 103:119,
1944.
i), Abercrombie, M. and Johnson, M.: Collagen content of rabbit sciatic
nerve during wallerial degeneration. J. Neurol. Neurosurg. Psychiatry
9:113, 1946.
20. Abercrombie, M. and Johnson, M.: The effect of reinnervation on
collagen formation in degenerating sciatic nerves of rabbits. J. Neurol.
Neurosurg. Psychiatry 10:89, 1947.

Self-Evaluation Quiz

The ____——— content of injured nerves increases as axons

penetrate the distal segment and mature.
a) Collagen
b) Cholesterol
c) Myelin
d) Protein
Which of the following considerations is the least important
factor determining the functional result after nerve repair?
a) Character of the wound
b) Exactness of suture technique
c) Other injuries
d) Timing of repair
Closed nerve injuries generally should be repaired after a
period of observation indicates lack of end-organ reinnerva-
tion.
a) True
b) False
TREATMENT OF NERVE INJURIES 407

4. Thickening of the epineurium and the ease with which

intraneural fibrosis can be judged favor primary suture.
a) True
b) False
5. Fibrous tissue is provoked by each nerve suture and
obstructs axon sprouting and maturation.
a) True
b) False

Answers on page 527.

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 Spastic and Paralytic
Hand Problems
Norman J. Cowen, M.D.

Objectives
The purpose of this presentation is to contrast the
clinical problems presented by the spastic and flaccid
* paralytic, and to discuss briefly the surgical management of
each, keeping their differences in mind.

Spastic and flaccid paralyses are two very different disease

entities, and therefore the treatment of each must be different.
The failure to recognize these differences has probably ac-
counted for many upper extremity surgical failures in spastics
over the past few decades. Because of these past failures, many
patients are denied surgical procedures that could really be of
benefit to them.
Anatomically, as we are all aware, spastic paralysis is an
upper motor neuron problem, while flaccid paralysis concerns
the lower motor neuron.
Clinically, the muscles in flaccid paralysis can be rated
according to strength and excursion, and the proper muscle
selected for transfer, with accuracy. In the spastic, however,
muscles cannot be rated. It is an “all or none” affair, and
sometimes it is difficult to tell if a muscle is working at all. It
may even be difficult to tell a spastic muscle from a tight band.
In some flexion deformities of the wrist, it may be difficult to
distinguish spastic overpull of wrist flexors from paralysis of

D.C.; President
Norman J. Cowen, M.D., Hand Surgeon, Washington,
Hand Research and
and Chairman, Board of Directors of the National
Extremity Rehabili-
Rehabilitation Fund, Inc.; Consultant, National Upper
tation Clinic, Washington, D.C.

409
410 N. J. COWEN

wrist extensors. Nerve blocking of the spastic muscles may be

helpful in this problem.
Another major difference is that flaccid muscles are under
precise voluntary control, whereas spastic muscles are not. It
must be remembered, therefore, that when transferring a spastic
muscle not under voluntary control, moving the muscle does
not give it cerebral control. Thus, the transfer does not make
much sense unless only a tenodesis effect is desired. If the
tenodesis effect is what is desired, one must further remember
that arthrodesis of an intervening joint will impair or eliminate
the tenodesis.
Spastic paralysis is quite variable in degree and is seen in
people of all ages (Fig. 1A and B). It can be congenital due to
brain malformation or due to anoxia at birth. One refers to
these patients as having cerebral palsy. Spasticity occurring in
adults is more often the result of a vascular accident.
Flaccid paralysis, to the contrary, has many types. Quadri-
plegics are a group unto themselves and will not be discussed in
this presentation. Brachial plexus injuries are fairly common
and the resultant paralysis is obvious. A typical case is a patient
shot through the axilla (Fig. 1C). Multiple peripheral nerve
injuries due to gunshot wounds and lacerations are included
under flaccid paralysis. Such disease entities as arthrogryposis,
syringomyelia, Charcot-Marie-Tooth and polio are also included.
Paralysis due to polio, which used to be so plentiful, is rarely
seen today. It often caused severe paralysis of the upper
extremity (Fig. 1D). Patients with early syringomyelia can be
very comely, and the paralysis hardly noticeable; intrinsic
atrophy may be the only sign on physical examination (Fig.
1E). Finally, in the treatment of Volkmann ischemic contrac-
ture, once the contracture is released, the patient is often left
with plain, ordinary flaccid paralysis.
The principles of treatment in any paralysis are the
prevention of deformity and the improvement of function.
Deformity in the spastic is best prevented by range-of-motion
exercises done with another’s help. I say “no” to splinting,
because range-of-motion is much better, and indeed splints are a
“people substitute.’’ However, following surgery, splints are
very helpful, and even in the absence of surgery, splints are
better than nothing, especially in situations where “people
help”’ is not available.
SPASTIC/PARALYTIC PROBLEMS Anda

FIG. 1. (A) A typical patient with cerebral palsy. (B) An adult with
cerebral palsy from childhood. (C) An adult with flaccid paralysis from a
gunshot wound to the brachial plexus. (D) A boy with severe paralysis of
the right upper extremity following shoulder arthrodesis. (E) A young lady
with Charcot-Marie-Tooth disease. Note the intrinsic atrophy in both
hands.

The goal of surgical treatment is to build an assisting hand.

This is usually much more important in the spastic than in the
flaccid paralytic because of the severe sensory impairment and
the awkwardness of movement noted in the spastic. No hand
with sensory impairment can be a leading hand unless the other
one is in worse condition.
412 N. J. COWEN

There are some mild spastics whose sensory impairment is

minimal and, indeed, they may even retain stereognosis. My
experience has indicated that these mild spastics are far better
off without surgery. Therefore, I feel that surgery should be
reserved for the moderate or severe spastic.
In flaccid paralysis we tend to rely primarily on tendon
transfers for surgical treatment. Arthrodesis is resorted to when
severe paralysis is encountered, or on occasion to free up
tendons that can be used for transfer. Tenodesis is occasionally
used (Table 1).
On the other hand, in the spastic, we tend to rely greatly on
arthrodesis, and much less so on tendon transfers. Arthrodeses
are reliable and permanent. Nonetheless, it should be empha-
sized that even though the wrist arthrodesis may be the best
technique in the spastic, its use in the wrong patient, or its use
in the right patient but at the wrong time, can make the patient
worse, rather than better.
Let us now put aside contrasting the two types of paralysis
and consider separately the treatment of the spastic. Later we
will deal with flaccid paralysis. First, how do we choose
candidates for surgery? I do it almost entirely on the basis of a
functional examination — by watching the patient perform
repeated activities. Figure 2 demonstrates an attempt to pick up
a set of keys. It is quite obvious that this patient’s main
problem is his inability to clear the palm of his thumb. Since
spasticity is increased by nervousness, each patient should be
examined several times before any conclusions are drawn. I
usually try to examine a child on two or three occasions,
without reading my notes from the preceding visit. If a
consistent pattern of treatment evolves, then and only then is

Table 1. Techniques for Reconstruciton

In flaccid paralysis
1. Tendon transfers
2. Arthrodesis
3. Tenodesis

In spastic paralysis
1. Arthrodesis
2. Tenotomies
3. Tendon transfers
 Note the
FIG. 2. Photographs of a spastic trying to pick up a set of keys.
to clear the palm of the thumb. This is known as the
inability
‘functional exam”’
thumb-in-palm deformity. This series demonstrates the
which is the best indicator for evaluating patients for surgery.
414 N. J. COWEN

the surgical procedure decided. A poor prognosis certainly

affects the candidacy of a patient for surgery. The sensory
examination does not affect candidacy in my experience,
because the patient’s eyes will substitute for sensation in an
assistive hand and often I do only a very cursory sensory
examination, if any at all. It used to be felt that good sensation,
and especially stereognosis, was a necessary condition for
surgery. However, only the mild spastic has good sensation.I
reiterate that, in my experience, the mild spastic is better off
without upper extremity surgery. Mental capacity is too
inaccurate a measure to be an indicator for surgery.
The rationale of surgical treatment for the spastic hand is to
decrease the number of moving parts so that the patient can
more accurately control what is left. This explains why
arthrodesis is the keystone of surgical treatment in the spastic.
It provides better control and more strength. Attempts to
decrease spasticity have met with poor success and play a role
only in distinguishing between paralysis and spastic overpull of
antagonists.
Distal to the elbow, four problem areas in the spastic need
to be considered: wrist flexion, the clenched fist, the thumb-in-
palm deformity and forearm pronation. If the patient has tight
finger flexors, it might be necessary for him to flex his wrist in
order to open his hand. Therefore, before the wrist flexion
problem is considered, tight finger flexors should be released
(Fig. 3A). This is easily performed by tenotomy of the profundi
and/or the sublimi at their musculotendinous junction in the
forearm. The skin is closed and the hand and wrist are
immobilized in plaster for six weeks in the neutral postion (Fig.
3B). As the patient recovers from general anesthesia and
spasticity recurs, the tendons will lengthen, regulated only by
the position in plaster, and will heal at this length. This
technique avoids the decision about precise tendon length,
which if made by the surgeon, inadvertently ends up with the
tendons being either too long or too short. The muscle belly
slide is a more involved procedure and has its best application in
the treatment of elbow flexion contractures. It should not be
used to release tight finger flexors.
Once the finger flexors have been released, the wrist flexion
problem can be approached. In the child, transfer of the flexor
 Cc
‘
deformity.
FIG. 3. (A) A spastic hand demonstrating the ‘‘clenched fist”?
of spastic
(B) Position of the hand and wrist in plaster following tenotomy
ate complica tion of the Green transfer.
flexor tendons. (C) An unfortun
proper preoperative
This excessive supination may have been prevented by
evaluation.
416 N. J. COWEN

carpi ulnaris to the extensor carpi radialis and brevis tendons,

otherwise known as the Green procedure, is a satisfactory
operation. In some cases it may permanently solve the wrist
flexion problem. Since the transfer is brought around the ulnar
side of the forearm, it also helps solve the pronation deformity
as well. This procedure, however, is not without its complica-
tions, the most dramatic of which is excessive supination (Fig.
3C). Proper preoperative evaluation of the forearm pronation
deformity, or lack of it, may prevent this unfortunate occur-
rence. In some spastics the tendon transfer will serve only as a
temporizing operation until the age of bony maturity, at which
time a wrist fusion can be performed. Figure 4 shows the hand
of a 28-year-old school teacher with spastic paralysis as she
attempts to extend her fingers. On every attempt her wrist
would first turn into severe ulnar deviation and flexion before
the fingers could be properly positioned. She was greatly
benefited by wrist fusion, despite the persistence of ulnar drift
of the fingers (Fig. 4C). A wrist arthrodesis, once and for all,
both stabilizes the wrist and increases control of the fingers.
The problem of forearm pronation is also illustrated by the
school teacher (Fig. 4B). This is treated by either tendon
transfer tenotomy or synostosis. The Green tendon transfer can
be a permanent solution in some cases, or as in some cases of
wrist flexion, it can give a temporary solution until the patient
is old enough for a synostosis. The benefit of tenotomy of the
pronator tendon is very short-lived, and it needs to be repeated
quite often. At best it is only a temporizing procedure until
synostosis can be done. The synostosis is best performed at the
distal radioulnar joint and is fixed with a transverse screw across
the two bones (Fig. 5A). This gives a very satisfactory result
both functionally and cosmetically when the forearm is placed
in 15° of pronation (Fig. 5B).
The last problem area to be discussed in the spastic is the
thumb-in-palm deformity (Fig. 6A). I believe that the procedure
which works most often is that used by Dr. Robert E. Carroll of
New York. This consists of a tendon transfer of a wrist flexor to
the thumb extensor in order to augment extension and
abduction, coupled with an arthrodesis of the metacarpophalan-
geal joint to prevent hyperextension. If the extensor pollicis
longus tendon is released from Lister’s canal, and kept dorsal to
the radial styloid, the vector pull on the thumb is halfway
 to
FIG. 4. (A) Hand of a patient with spastic paralysis as she attempts
(B) Same hand, demonstra ting the pronation deformity
extend her fingers.
functional
of the forearm as well. (C) Following arthrodesis, with great
improvement despite residual ulnar drift of the fingers.
418 N. J. COWEN

FIG. 5. (A) Radiogram of a patient following surgical synostosis of the

distal radioulnar joint (technique of Dr. Robert E. Carroll of New York).
(B) Same patient, demonstrating ideal position of 15° of pronation.
SPASTIC/PARALYTIC PROBLEMS 419

deformity. (B)
FIG. 6. (A) Spastic hand demonstrating the thumb-in-palm
Same hand followin g a Carroll procedur e.
420 N. J. COWEN

between extension and abduction (Fig. 6B). The motor can be

the palmaris longus or the flexor carpi radialis. Most often this
transfer comes under voluntary control but other times it will
function only as a tenodesis. In the latter cases, subsequent
arthrodesis of the wrist should not be performed, or the
tenodesis effect will be lost.
When a thumb remains in a flexed position in the palm, it is
either because it is held there forcefully or because there is
insufficient force to pull it out, or a combination of both. The
Carroll procedure provides a powerful abduction force. In some
cases it is also necessary to relieve the adductor-flexor mass,
which is best done at the muscle origin (Fig. 7). This soft tissue
release can be performed in the very young child either as a
definitive procedure or as a temporizing one until the child is
old enough for a Carroll procedure at age 7 to 9.
No matter what operation is done on the spastic, one should
remember that it takes a very long time for them to adapt and
long intervals between procedures should be anticipated, with
multiple visits for reevaluation.
Let us now turn briefly to flaccid paralysis. There is a
relatively easy way to approach the evaluation of a patient with
flaccid paralysis in the upper extremity. First of all, the
paralysis can be localized or generalized and, second, the
paralysis of each muscle can vary from mild to severe. To tackle
all these problems at once may take a very long time. One can
evaluate a paralytic in a short time as follows: First do a gross
functional examination by area, noting which area has sufficient
function and which needs attention. Then check to see what
muscles are available or could be available. Finally, sketch a
preliminary plan.
There are essentially seven areas to check in the upper
extremity of a patient with flaccid paralysis: (1) At the
shoulder, see if there is sufficient power to raise the humerus
enough for the hand to reach the forehead; also check for an
internal rotation deformity. (2) At the elbow, only flexion is
needed (quadriplegics excepted). (3) At the forearm, check for
supination and pronation. (4) At the wrist, look for flexion and
extension. (5) Check flexion and extension of the fingers.
(6) Check the thumb for opposition. (7) To evaluate the
intrinsics, look for clawing.
SPASTIC/PARALYTIC PROBLEMS 421

deformity
FIG. 7. Diagram of the soft tissue release for the thumb-in-palm
at the origin of the adductor and short flexors of the thumb.
422 N. J. COWEN
SPASTIC/PARALYTIC PROBLEMS 423

FIG. 8. (A, B) Patient with flaccid paralysis, demonstrating the use of

sternocleidomastoid tendon transfer to provide elbow flexion. A severe
muscle deficit prevented the easier-to-perform Steindler transfer or triceps
transfer. A shoulder fusion had been performed earlier. (C) Frontal view
demonstrating the bulge in the neck. (D) Same patient, demonstrating the
salute position. (E, F) A polio patient with a sternocleidomastoid tendon
transfer, demonstrating how a turtleneck sweater hides the bulging seen in
(C). (Photos courtesy of Dr. Robert E. Carroll.)

If there is significant weakness in any area, check to see

what muscles are available for transfer. A list of the usual ones,
but by no means a complete list, is as follows: The triceps can
be used as an elbow flexor. The brachioradialis has 4 cm of
excursion and can be a good transfer. The pronator teres or
extra wrist extensors and flexors are good transfers. If the
profundi are intact then functioning sublimi may be available.
Finally, the proper extensor tendons of the index and little
fingers may make good transfers.
If there is a severe shortage of available tendons, one should
fused or if
check to see what could be available if the wrist were
the distal radioulnar joint were fused.
424 N. J. COWEN

FIG. 9. Typical flaccid paralysis of wrist extensors with the finger

extended (A) and flexed (B). This is best treated by tendon transfer or
arthrodesis.
SPASTIC/PARALYTIC PROBLEMS 425

For shoulder weakness seen in polio, after trauma or in

arthrogryposis, think of arthrodesis if scapular rotation is intact.
If there is internal rotation of the shoulder, as often seen in
Erb palsy, consider soft tissue releases. The L’Episcopal
operation adds a tendon transfer to the release to augment
external rotation. Often the easiest and best procedure may be a
derotation osteotomy of the humerus.
For elbow flexion weakness as seen in polio, after trauma or
in arthrogryposis, first think of the Steindler flexor plasty, then
perhaps the triceps transfer. If one is desperate and nothing
seems available, there is almost always a sternocleidomastoid
muscle available (Fig. 8). It requires a long fascia lata graft. The
rather offensive bulging of the neck (Fig. 8C) can be hidden by
a turtleneck sweater (Fig. 8E and F).
The forearm synostosis to control supination and pronation
has already been discussed. Wrist drop can be treated by tendon
transfer or arthrodesis (Fig. 9).
Tendon transfers for finger flexion, extension and thumb
opposition are numerous and will not be discussed in this
presentation.
In summary, for the flaccid paralytic, evaluate missing
function by area. Decide what muscles are available or could be
available and then put together a tentative plan. Always keep in
mind whether the patient is a reasonable candidate.
In the spastic, one is emphatic about preventing deformity.
We must recognize the limits in the goals of surgical treatment.
Think in terms of the functional examination, and repeat it
often. Remember that long intervals are needed between
surgical procedures. Think of bony stabilization to decrease the
number of moving parts, rather than tendon transfers as in the
flaccid paralytic. Finally, give some consideration to the
cosmetic aspects as well as the functional gain.
In any event, do not fall into the trap of thinking that all
paralytics are similar!

Self-Evaluation Quiz

1. The treatment of flaccid and spastic paralyses is similar

since both involve nonfunction of certain muscle groups.
a). Lrue
b) False
426 N. J. COWEN

2. Transfer of a spastic muscle will help to put it under

cerebral control where it can aid movement of a paralyzed
joint.
a) True
b) False
3. Spastic muscles cannot be rated; they either work or don’t
work. This is different from flaccid muscles, which can be
rated from zero to normal.
a) True
b) False
4. A wrist arthrodesis, the mainstay procedure in spastic
paralysis, can do more harm than good if used in the wrong
patient or in the right patient but at the wrong time.
a) True
b) False
5. At least average intelligence is an important prerequisite for
a spastic paralytic to be a candidate for reconstructive
surgery.
a) True
b) False
6. Spastic patients perform worse when nervous, and therefore
should be evaluated on more than one occasion before a
decision is made on surgical procedures.
a) True
b) False
7. The Jones tendon transfer (a three-tendon transfer) or the
Carroll tendon transfer (a two-tendon transfer) is used in
the flaccid paralytic to replace paralyzed wrist, finger and
thumb extensors.
a) True
b) False
8. The sternocleidomastoid tendon transfer for elbow flexion
is an excellent transfer and is preferred to the use of more
local muscles such as the Steindler flexor plasty or the
triceps transfer.
a) True
b) False
9. In the spastic, there is little need for the distal radioulnar
arthrodesis since tendon transfers or tenotomy procedures
are usually definitive.
 SPASTIC/PARALYTIC PROBLEMS 427

a) True
b) False
10. In the spastic, the ‘clenched fist’? problem should be
attended to before the wrist flexion problem.
a) True
b) False

Answers on page 527,

~~, y
 Two-Stage Tendon Reconstruction
Using Gliding Tendon Implants
James M. Hunter, M.D.

Objective

Following mutilating trauma to the hand, the early

priorities of treatment should emphasize the maintenance
of good circulation, protective skin coverage, proper align-
* ment of the bones and joints and the restoration of a soft
bed for tendon gliding. Tendons not severed or severely
crushed may be taught to glide again by supervised motion
programs. Often, however, in spite of careful primary
treatment, the tendon and the tendon sliding bed have been
so damaged that a healing complex of scar develops and
function is lost. It is the purpose of this chapter to outline
the techniques of two-stage tendon reconstruction using a
gliding tendon implant to assist organization of a new
tendon bed prior to tendon grafting.

The Implant

Two tendon implant programs have evolved from experi-

ence gained in experimental and clinical research during the past
16 years: (1) a passive gliding program, and (2) an active gliding
program.

The Passive Gliding Program [{1, 2]

This program implies that the distal end of the implant is
fixed securely to bone or tendon while the proximal end glides
free in the proximal palm or forearm. Movement of the implant

James M. Hunter, M.D., Associate Professor of Orthopedic Surgery,

Jefferson Medical College; Chief of Hand Surgery, Thomas Jefferson
University Hospital, Philadelphia, Pa.
Reprinted, with permission, from Operative Surgery, 3rd ed. Copyright
1979, Butterworths.

429
430 J. M. HUNTER

is produced by active extension and passive flexion of the digit.

The implant incorporates design characteristics of firmness and
flexibility to permit secure distal suture fixation and minimize
the buckling effect during the passive push phase of gliding (Fig.
A). Limited active motion may be achieved by adding a
proximal suture to this implant; however, the patients must be
carefully supervised or terminal separation will take place with
possible compromise of stage 2 tendon grafting.

i
BA
RS
RG
anne
er
OE
SERS
28

ae
a

The implant is available commercially as the Hunter Tendon

Implant* in widths of 3, 4, 5 and 6 mm. The implants have
radiopaque properties for x-ray location between stages 1 and 2
and a tapered proximal end to adapt the implant better as a
surgical obturator. Standard lengths may be shortened using a
scalpel at the time of surgery.

Active Gliding Program and Implant

The early concept (1960) was the design of an artificial
tendon or prosthesis. Limited success was achieved and pub-
*The Holter Company, a Division of Extracorporeal Medical Special-
ties, Inc., Royal and Ross Roads, King of Prussia, Pa. 19406, U.S.A./215-
337-2400. In Europe, write to Extracorporeal S.A., 253 Ave. Winston
Churchill, 1180 Brussels, Belgium.
TWO-STAGE TENDON RECONSTRUCTION 431

lished [3], but due to terminal juncture separation under stress,

the method was converted to passive gliding until more
advanced research could produce proximal and distal attach-
ments that were reliable for extended periods.
Currently, new synthetic fibers are being studied for the
body of the implant and loop systems and titanium composites
for the terminal ends. All implant shafts are pressure-mold
processed for lifetime flexibility and gliding. Primate and
limited clinical study programs are currently in progress and
when reliability can be predicted, active implants will be made
available to augment the passive gliding program [4].

Care of Tendon Implants

Meticulous care of silicone rubber products should be

considered at all times. Surface soilage can occur easily due to
static charge and lint attraction.
At surgery, the implant should be transferred from the
sterile lint-free package with moistened gloves to a triple
antibiotic solution or saline. Handle implants on wet sponges
and continually irrigate the tendon bed. The author suggests
that a set of four implants be set aside as sizer implants to be
cleaned and sterilized after each case.

Preparation of Bed for Tendon Implant

Stage 1
Scarring of the gliding bed will depend on the extent of
injury and vary from small segments, i.e. failed primary tendon
repair, to complete involvement of the anatomical limits of the
sheath, i.e. failed tendon graft or infection. Preparation of the
digit before insertion of the implant requires the following:
(1) The zig-zag incision has become the standard incision for
flexor tendon reconstruction, permitting meticulous resection
Joint
of scar tissue while preserving soft tissue nutrition. (2)
skin
contractures should be released by excision of scarred
loss may
ligaments and capsulectomy. Scarred areas of skin
skin flaps over implant bed and lateral seg-
require shifting
may be
mental thick skin grafting. (3) Digital neurorrhaphy
ion of
indicated if a suitable bed can be established. (4) Preservat
Uninjured
annular ligaments and new pulley construction.
432 J. M. HUNTER

portions of the sheath system should be preserved. Instru-

mentation will usually be necessary to dilate contracted annular
sections. New pulley reconstruction will be required where
injury and scarring are extensive. The surgeon must always be
conscious of the fact that final function is progressively
compromised as the retinacular pulley system is reduced in size
and number. The size, strength and location of reconstructed
annulus should correspond as closely to the original as
possible [5]. (Figure B shows the author’s 1979 modification.)

2 f ; ere
Keune | oe i :4

ew
: A2 a A3 ce A4 C5
|YY x b rE J
B ). ) i PX. > ) v/

Considering all clinical factors, the hand should be suf-

ficiently soft and ready for stage 2 tendon grafting by three to
four months. Under certain circumstances, particularly if a
mechanical synovitis occurs, earlier tendon grafting at six weeks
is indicated. The sheath cell system will support tendon grafting
as early as four weeks [4].

Stage 2
Stage 2 requires only minimal disturbance of the terminal
portions of the new sheath sufficient to accept the tendon graft
and terminal attachments. The new pseudosheath will support
the tendon graft early by fluid secretion and later by filmy
adhesions [6-9].

Preoperative Planning

The objective of the staged flexor tendon implant program

is to improve the predictability of final results — therefore, the
surgeon capable of achieving a good result with flexor tendon
grafting in a tendon bed with minimal scarring may now see
similar results in the poorer grade cases, using the two-stage
method. We suggest that patients who are considered suitable
candidates for tendon grafting and tenolysis also be considered
TWO-STAGE TENDON RECONSTRUCTION 433

candidates for a tendon implant, for only at the time of surgery

can the surgeon make a true estimate of the extent of tendon
bed damage.
A tendon implant is indicated in the following situations:
1. A temporary segmental spacer in selected primary
injuries where tendon repair is not possible. We believe
that when the conditions are favorable, a primary flexor
tendon repair is the procedure of choice.
2. Scarred tendon beds where a one-stage tendon graft can
be predicted to fail.
3. Salvage situations where, in spite of predicted degrees of
stiffness, scarred tendon bed and reduced nutrition,
useful function can be returned to the remaining hand
segments.
Prior to tendon surgery, all patients should be placed on a
hand therapy program designed to mobilize stiff joints and to
improve to the maximum the condition of the soft tissues. The
timing of stage 1 tendon surgery should finally combine the
judgment of surgeon, hand therapist and patient, for patient
input and motivation are the key to a successful result.

Chemotherapy

All patients with tendon implants are considered similarly as

for Swanson joint implants. Perioperative antibiotics are recom-
mended just prior to surgery and for 72 hours thereafter. Triple
antibiotic solutions are used both on the implant and soft tissue
surfaces during surgery.

Anesthesia

Stage 1
If patient participation is required to determine function,
i.e. tenolysis vs. implant, we recommend local anesthesia and
tourniquet augmented by narcotic and sedative medication. The
successful program in our clinic has been (1) preoperative
preparation of the patient to assist actively at surgery, (2) intra-
venous Innovar (droperidol and fentanyl), monitored by a
qualified anesthesiologist, (3) local 1% Xylocaine given with a
No. 27 gauge needle in the zig-zag incision line, and (4) tourni-
434 J. M. HUNTER

quet release at 30-minute intervals to examine function. If the

preoperative evaluation clearly indicates extensive tendon dam-
age beyond tenolysis, general anesthesia and tourniquet are
utilized.

Stage 2
A majority of patients will do best with general anesthesia
and tourniquet. Axillary nerve blocks have been used at times as
an alternative technique to general anesthesia. In certain
selected cases where a suitable tendon graft can be taken from
the arm, the Innovar and local program have been used
successfully, permitting an accurate determination of motor
tendon unit amplitude. Other surgeons have reported the
successful use of the double-tourniquet vascular block with
release of tourniquet prior to the final tendon juncture, again
permitting an assessment of motor unit amplitude.

Postoperative Technique

Stage 1
Where there were joint contractures prior to insertion of the
prosthesis, intermittent stretching splints may be required to
prevent recurrence of the contracture. Intermittent elastic
finger traction may be started during the first postoperative
week. Gentle passive motion of all joints is started gradually
during the second to the fourth week. Regular passive stretch-
ing, under the supervision of a hand therapist, is begun in the
fifth week and the patient is taught at this time to flex the
finger whenever possible, using an adjacent finger hooked over
the damaged one. Usually, by the sixth week, there is a
functional range of passive motion. During this time the hand
should be examined regularly for evidence of synovitis in the
new sheath. If this has not developed within the first six weeks,
it is not likely to occur and the patient may resume normal
activities, including going back to work, until he is ready for the
second stage. If synovitis develops, as evidenced by swelling, the
finger and wrist should be immobilized promptly and, if the
synovitis persists, the distended joints should be carefully
mobilized daily and the sheath may decompress to the surface.
The second-stage procedure should be done early before chronic
fibrosis develops. A clean drainage synovitis, managed by good
TWO-STAGE TENDON RECONSTRUCTION 435

surgical principles, is not a contraindication to stage 2 tendon

grafting.

Stage 2
Early protected flexion of the grafted finger is encouraged,
while a padded dorsal splint prevents sudden forceful extension.
Intermittent splinting may be continued during the fourth week
while the pull-out suture and button are still in place. In the
fifth week, the pull-out wire is removed and light passive
stretching exercises may be started if necessary. Patients must
be carefully instructed how to slide the tendon graft through
the new sheath by holding the metacarpophalangeal joints
against the table in extension during flexion of the distal joints.
This basic technique is also applied when squeezing the Bunnell
wood block and small aspirin bottles. These training techniques
may be required for several months. There are two complica-
tions after stage 2 tendon grafting that deserve discussion:
(1) adhesions along the tendon graft or at the proximal
anastomosis, and (2) rupture of the anastomosis of the tendon
graft. If tenolysis is necessary, it is performed three to six
months after stage 2 using local anesthesia, Innovar analgesia
and a tourniquet. The region of the proximal anastomosis
should be explored first, with attention directed initially to the
junction of the new tendon sheath and the tendon graft; next,
to the proximal anastomosis; and, lastly, to the tendon graft
within the new sheath. Only adhesions which actually restrict
motion should be lysed.
After surgery, immediate active motion of the lysed tendon
graft is necessary to preserve the increased ranges of motion.
436 J. M. HUNTER

THE OPERATIONS

STAGE 1

1
Preoperative assessment of the range of
mo tion (active vs. passive)
The degree that the finger joints lack in extension and the
distance that the finger pulp fails to touch the distal palmar
crease are recorded. These measurements should be made part
of the permanent record of each patient for progress compar-
ison and follow-up measurements noted (a) six weeks after stage
1, (b) at stage 2 replacement grafting, plus (c) monthly after
stage 2.

Eee
aN
ty armeeccteciorn, ay alte were pert
RE GN we
TWO-STAGE TENDON RECONSTRUCTION 437

2a
Incision for flexor tendon reconstruction
Finger
The volar zig-zag incision, popularized by Julian Bruner, is the
incision of choice. This incision spares the deep vascular
connections to the tendon bed and permits a complete exposure
of the tendon bed. Note that the points of the incision stop
approximately over the neurovascular bundle. Neurovascular
bundles must be carefully protected.

2a

2b
Palm
The finger incision may connect a continuous Zig-zag into the
palm. Traditional palmar incisions paralleling the creases give
excellent proximal exposure but leave a blind area in the distal
palm when A-1 or A-2 pulley reconstruction may be necessary.
 J. M. HUNTER
438

Forearm
Only rarely has an incision across the carpal tunnel been
necessary. The isolated gentle forearm curved incision is
preferred and this is placed either over the flexor carpi radialis
or flexor carpi ulnaris to separate wound healing of the skin
from tendon juncture healing.

es

rs

fea)

wi
“ees
ae
ef
brs
TWO-STAGE TENDON RECONSTRUCTION 439

3a
Excision of damaged tendons
This portion of the operation will often be time-consuming. The
surgeon must carefully excise scarred and adherent tendons
while preserving uninjured portions of the sheath retinaculum.
A generous segment of the distal profundus tendon is preserved
and the joint capsule is left intact.

3b
If the superficialis tendon bed has not been injured, it is left
intact over the proximal interphalangeal joint. Scarring of the
tendons at the proximal interphalangeal joint level is often
responsible for a flexion contracture. Meticulous dissection of
mature scar at this level will permit increased ranges of motion
and minimize flexion contracture after stage 2. Care must be
taken to preserve the volar proximal interphalangeal joint
capsule.
440 J. M. HUNTER

4
Preserve annular portions of sheath
If considerable scarring of the tendon bed is encountered, it is
safest to begin the excision of scarred tendon proximal to the
proximal interphalangeal joint and at midportion of the
proximal phalanx between the locations of the anatomical
annulus. Collapsed annulus may be dilated with fine hemostats.
Severely scarred segments of sheath should be removed and
later replaced with new pulleys.

ce)
Division of flexor tendons in palm and excision
of lumbrical muscle in palm
The profundus and superficialis tendons are removed from the
proximal annulus and sharply divided in the proximal palm.
Scarred lumbrical muscle is resected. If the palm is uninjured,
the lumbrical and profundus complex with surrounding meso-
tenon is carefully preserved for stage 2 juncture.
TWO-STAGE TENDON RECONSTRUCTION 44]

6a,b&c
Release of joint and skin contractures
If resection of scarred tendons fails to release the contracture,
scarring of the joint capsule and/or skin ligaments should be
suspected. Capsulotomy of volar accessory collateral ligament
and volar plate (a) will release contracture if confined to the
joint only. The cord portion of the joint ligament is preserved
for stability. Scarring of skin, the Cleland and/or Landsmeer
ligament complex on either side of the finger will maintain a
contracture and may require (b) opening a V and Y incision or
(c) shifting the skin flap and skin grafting. The joint should be
immobilized postoperatively with a K wire for 10 days,
followed by controlled intermittent splinting. These procedures
will be most effective if the neurovascular bundle on only one
side of the finger is damaged. In all instances of release, the
tourniquet should be deflated and the vascularity of the finger
inspected frequently. In poor situations, arthrodesis or amputa-
tion may be indicated.

a,
=X ANE
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442 J. M. HUNTER

fa
Pulley preservation and reconstruction
The original annular retinaculum is preserved by sharp incision
of adjacent sheath material and the remaining annulus should be
dilated by instrumentation. If the annular segments are of
insufficient size to carry the implant, they should be excised,
leaving a flap of the base portion into periosteum for suture
during tendon graft pulley reconstruction.

A1 A2 A3 A4

Tendon material (flexor digitorum superficialis) to be discarded

is excellent for pulley building. Several techniques may be
applied, depending on the location of injury and the surgeon’s
preference. The author recommends following certain princi-
ples: wide pulleys (full-width tendon grafts) are superior to
small or narrow grafts.

1c
Pulleys should be roomy and not bind the implant or graft.
TWO-STAGE TENDON RECONSTRUCTION 443

S8a-e
Specific techniques of flexor tendon
pulley reconstruction
(a) Pulleys should be placed close to the joints to increase
efficiency and decrease tendency to bowing and post-stage 2
joint contracture.
(b) Free tendon passed around bone.
(c) Free tendon passed through bone.
(d) Free tendon to remnants of annular band.
(e) Slips of free tendon laced through remnant of annulus.
(f) Tail of superficialis sutured across base of middle phalanx.
444 J. M. HUNTER

9&10
Tendon implant sizers are passed through the pulley system.
Finger is held flat on the table; implant is moistened and pulled
gently back and forth. Principle: select smaller implant and
larger pulley. Through the forearm incision, superficial and deep
flexor tendon structures are identified and a preliminary
determination oi a stage 2 motor tendon unit is made. A
malleable blunt tendon carrier is passed deep through the carpal
tunnel to present in the forearm deep to the superficialis and
superficial to the profundus. The instrument is passed gently,
seeking the soft mesotenon spaces. The proximal end of the
implant is pulled into the forearm through the eye of the passer.
The distal end is passed through the first pulley (A-1) using
alligator jaw tendon passer, and the moistened implant may be
passed distally through the distal (A-4) pulley. Implant binding
will occur most often at the narrow flap distal (A-4) annulus
requiring tendon graft pulley reconstruction.
TWO-STAGE TENDON RECONSTRUCTION 445

11
The length of the implant is determined so that on full
extension of the finger, the proximal end can be seen proximal
to the wrist crease. Excess implant is trimmed off distally with a
scalpel. Distal end fixation is accomplished with an interlocking
monofilament 4/0 wire, using taper cut (R) needles to minimize
damage to the implant.

12a
Using sharp dissection, the flexor digitorum profundus stump is
freed to its distal attachment fibers to the distal phalanx. The
implant is sutured snug under the flexor digitorum profundus
stump. Lateral sutures reinforcing the profundus stump tendon
implant and periosteum are placed with 5/0 multifilament wire.
The implant should feel secure and well fixed.

12a
A4G J. M. HUNTER

12b&c
Alternate techniques for distal attachment
If for some reason the flexor digitorum profundus tendon
stump is absent, the implant wire sutures are passed through
two drill holes in the base of the distal phalanx. The implant is
snuggled against the bone and the sutures tied on the dorsum of
the distal phalanx. Lateral reinforcing sutures are placed in
periosteum.
Figure 12c shows a tendon implant by Holter-Hausner
International.

12b
MN|

13
Passive gliding of the implant is tested by moistening the
implant bed with saline, holding the wrist and digit in neutral
while passively flexing and extending the finger. Motion should
be free with measured range of motion between 3 and 4 cm at
the proximal end. Buckling of the implant occurs distal to tight
sheath and, if present, must be corrected before closure or a
synovitis will develop between stages 1 and 2.

eV AAD IKGeag, ic s
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TWO-STAGE TENDON RECONSTRUCTION 447

14
Testing pulley system and recording
range of motion
This is the important last maneuver of stage 1 before wound
closure. The free proximal end of the implant is grasped and
pulled, bringing the finger from extension to maximum flexion.
The following are recorded :
i The predicted active range of motion vs. the passive
range of motion.
vi The measured distance of the proximal end necessary to
produce the active function. This will assist in selection
of stage 2 motor tendon.
The attitude of the finger in relation to the pulley
system: Is another pulley necessary to improve func-
tion? Should a sagging pulley be snuggled closer to
bone? A pulley may rupture during this maneuver,
requiring resuturing or a tendon graft.
Finally, after these forceful maneuvers the security of
the distal end attachment of the tendon implant should
be carefully checked.

The wound is closed distal to proximal and finally the soft

a
tissue recess for the implant in the forearm is checked with
The
moistened gloved finger and passive gliding is reviewed.
448 J. M. HUNTER

hand is positioned with wrist and metacarpophalangeal joints in

flexion for closure and final dressing. This position after stage 1
permits the proximal sheath to form in the long position.

16
Between stage 1 and stage 2, the movement and position of the
implant sould be checked by x-ray in extension and flexion —
six weeks and the day prior to stage 2 are suggested.
TWO-STAGE TENDON RECONSTRUCTION 449

STAGE 2

17
Replacement of implant with tendon graft
On the operating table, the passive range of motion is recorded
to be compared with the stage 1 range of motion (see Fig. 1).
Improvements are frequently noted after stage 1 hand therapy.
Distal and proximal incisions are made to identify the sheath
and implant. Distally, the implant is left attached to the tendon
stump. Proximally, the implant is grasped with an instrument
(rubber-shod forceps) and the sheath at the site of juncture is
carefully examined. Portions of soft sheath may be retained at
the surgeon’s discretion; however, if synovitis has been present,
the thickened sheath must be completely removed at the
proximal juncture site to the wrist flexion crease. The active
potential range of motion is recorded starting with the hand and
finger flat on the table (see Fig. 14). The measured rule is held
by the proximal end of the implant. The implant is pulled
firmly and the surgeon should note (a) the excursion of the
implant to produce the range of motion from maximum
extension to maximum flexion; (b) the distance the finger pulp
rests from the distal palmar crease; (c) joint with restricted
motion; (d) the easy gliding of the implant and the fluid
lubrication system of the tendon bed.
450 J. M. HUNTER

18
The motor tendon is selected and grasped with a small
hemostat. The hand is elevated and the tourniquet released
while the lower leg is prepared to remove a long plantaris
tendon graft. The technique is as that described by Paul
Brand [10] (see page 244 in The Hand volume). The author has
frequently used a long toe extensor tendon when the plantaris is
absent. This technique uses the Brand type stripper and two
incisions: (a) distally over the metatarsal joint of toe three or
four; (b) proximally at the retinacular level of the ankle.
TWO-STAGE TENDON RECONSTRUCTION 451

The graft is freed in the distal segment and passed to the

proximal incision and stripped to the muscle attachment.
Excellent long grafts have been removed by these techniques.
Shorter tendon grafts, palmaris longus, extensor indicis, exten-
sor digiti minimi and segments of superficialis are removed by
standard technique and may be used for (a) thumb, little finger
and superficialis fingers with the long juncture in the forearm,
or (b) index, long and ring fingers to a tendon juncture in the
uninjured palm.

19
Removal of tendon implant and
insertion of tendon graft
The tendon graft, carefully stripped of peritenon, is sutured to
the proximal end of the implant and pulled through the new
tendon bed. The implant is detached from the distal phalanx
and discarded.
A52 J. M. HUNTER

20
The distal juncture
The tendon graft may be secured distally by a Bunnell-type
suture technique to bone. The author currently prefers tendon
fixation to the base of the distal phalanx to passing the wire
tendon suture through two small drill holes noted on the
dorsum of the phalanx just distal to the extensor tendon
insertion. The wire suture is instrument flattened against the
bone and the skin closed. Reinforcing sutures further secure the
tendon to volar periosteum. The distal incision is closed.

21
Selection of motor tendon
The tendon graft and the motor tendon are grasped with
instruments and, with the wrist neutral, the needed excursion of
tendon graft is measured. The selected motor tendon must
supply the same excursion or better if a good result is to be
achieved.

21
TWO-STAGE TENDON RECONSTRUCTION 453

22a&b
The proximal juncture
The Pulvertaft end weave technique (Fig. 22a) is preferred for a
single tendon juncture, i.e. profundus of index, flexor pollicis or
superficialis. The multiple [11, 12] end weave is preferred for a
profundus, long, ring or little finger juncture. Interrupted
monofilament British No. 32 gauge wire is our suture of choice
for proximal end attachment. Using a technique taught us by
Mr. Pulvertaft, the wrist is placed at neutral, the tendon graft is
passed through the motor tendon and fixed with a single suture
with long ends, with the finger falling in slightly more flexion
than normal. The wrist is passively flexed and extended. If
adjustment is necessary, the wire suture is cut and tension
readjusted. After repeated manipulations of the finger, it
remains in slightly more flexion than normal. The juncture is
completed by a second interweave and suture fixation and the
wound is closed. The postoperative plaster splint dressing fits
securely with the wrist in 30° of flexion, metacarpophalangeal
joints in 70° of flexion and interphalangeal joints slightly flexed
or extended. Light activity on the part of the patient is
permitted with no resistance (see Fig. 15).
454 J. M. HUNTER

23
The superficialis finger — an alternative
salvage technique
Stage 1
The implant is carried to the base of the middle phalanx and
fixed in place by a wire suture passed through two small drill
holes. Reinforcing sutures are added. The distal phalanx is
either tenodesed or arthrodesed.
Stage 2
Reconstruction for superficialis finger follows the same pro-
cedures as described for tendon grafting to the distal phalanx. If
the range of motion at the metacarpophalangeal and proximal
interphalangeal points is good, the superficialis finger is a very
acceptable salvage technique.

24
The superficialis finger by tendon graft
recession
After stage 2 tendon grafting, a pulley rupture, distal or
proximal to the proximal interphalangeal joint, may result in a
bowed finger. A useful result may be salvaged by detaching the
tendon graft distally and attaching the graft to the base of the
middle phalanx. Tenodesis or arthrodesis of the dorsal inter-
phalangeal joint completes the procedure.

ages “a
:ep Sy
TWO-STAGE TENDON RECONSTRUCTION 455

25
Extensor tendon reconstruction
Stage 1
A small or medium tendon implant may be passed from the
forearm, dorsum of the base of the proximal phalanx or the
dorsum of the base of the middle phalanx.
The implant is sutured to bone by the two small drill-hole
technique and covered with remnants of the extensor tendon. A
pulley to help the implant centralize is essential and may be
made from the available extensor tendon or free graft material.
The lateral band system should be functional on one side for a
good result.

Acknowledgment

The illustrations for this paper were redrawn by Mr. M. J.

Courtney.

References
ction in
1. Hunter, J.M. and Salisbury, R.E.: Flexor tendon reconstru
severely damaged hands. J. Bone Joint Surg. Boer 78), ISI.
implants to
2. Hunter, J.M. and Salisbury, R.E.: Use of gliding artificial
sheaths. Techniqu es and results in children. Plast.
produce tendon
Reconstr. Surg. 45:564, 1970.
and application.
3. Hunter, J.M.: Artificial tendons. Early development
Am. J. Surg. 109:325, 1965.
tendon prosthesis:
4. Hunter, J.M. and Jaeger, S.H.: The active gliding
Hand. American
Progress. In Symposium on Tendon Surgery in the
edic Surgeon s, 1975, pp. 275-282 .
Academy of Orthopa
flexor tendon sheath and
5. Doyle, J.R. and Blythe, W.: The finger
and reconst ruction . Jn Symposium on Tendon
pulleys: Anatomy
456 J. M.HUNTER

Surgery in the Hand. American Academy of Orthopaedic Surgeons,

1975, pp. 81-87.
. Hunter, J.M., Subin, D., Minkow, F. and Konikoff, J.: Sheath
formation in response to limited active gliding implants (animals). J.
Biomed. Mater. Res. Symp. No. 5 (part 1):163, 1974.
. Hunter, J.M., Steindel, C., Salisbury, R. and Hughes, D.: Study of
early sheath development using static nongliding implants. J. Biomed.
Mater. Res. Symp. No. 5 (part 1):155, 1974.
. Rayner, C.R.W.: The origin and nature of pseudo-synovium appearing
around implanted Silastic rods. An experimental study. Hand 8:101,
1976.
. Urbaniak, J.R., Bright, D.S., Gill, L.H. and Goldner, J.L.: Vasculariza-
tion and the gliding mechanism of free flexor-tendon grafts inserted
by the silicone-rod method. J. Bone Joint Surg. 56A:473, 1974.
. Brand, P.: Principles of free tendon grafting, including a new method
of tendon suture. J. Bone Joint Surg. 41B:208, 1959.
iil. Pulvertaft, R.G.: Experiences in flexor tendon grafting in the hand. J.
Bone Joint Surg. 41B:629, 1959.
We Pulvertaft, R.G.: Tendon grafts for flexor tendon injuries in the
fingers and thumb. A study of technique and results. J. Bone Joint
Surg. doB:1 75, 1956.

Self-Evaluation Quiz

Movement of the passive gliding implant is achieved by

active extension and passive flexion of the finger.
a) True
b) False
A two-stage tendon implant is not indicated in the presence
of stiffness and a badly scarred tendon bed.
a) True
b) False
During surgery, the tourniquet should be released at
minute intervals to examine function.
a) 10
b) 15
C)aeZ0
dje25
e) 30
A majority of patients at stage 2 do best with:
a) Axillary nerve block
b) General anesthesia and tourniquet
c) Innovar plus local anesthesia
d) Double-tourniquet vascular block
TWO-STAGE TENDON RECONSTRUCTION 457

5. If synovitis develops, stage 2 must be deferred.

a) True
b) False
Following stage 2, adhesions may occur along the graft and
should be removed at three to six months.
a) True
b) False
After surgery, immediate active motion of the lysed tendon
is necessary to preserve range of motion.
a) True
b) False
Superficialis tendon material to be discarded is excellent for
pulley building.
a) True
b) False
Scarring of skin, the Cleland and/or Landsmeer ligament
complex may require:
a) Resection
b) Capsulotomy
c) V-Y incision
d) Skin grafting
10: At full extension of the finger, the proximal end of the
implant should be seen proximal to the wrist crease for
correct length.
a) True
b) False
A
Wa Passive gliding motion of the implant should range between
2 and 3 cm at the proximal end.
a) True
b) False
APA, The postoperative plaster splint should hold the wrist in 30°
flexion, metacarpophalangeal joints in 70° flexion and
interphalangeal joints slightly flexed or extended.
a) True
b) False

Answers on page 527.

 3

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 Hand Therapy Program for Staged
Tendon Grafting Using Gliding
Tendon Implant
(Hunter Design)
Evelyn J. Mackin, L.P.T.

Objective
The preoperative and postoperative hand therapy pro-
gram is an important part of two-stage tendon reconstruc-
tion. This paper is intended to acquaint the surgeon and
physical and occupational therapist with guidelines for
early motion. Each patient is an individual and the
postoperative treatment must be tailored according to the
surgical procedure and the patient’s progress.

The successful result of two-stage tendon reconstruction

depends in great part on the preoperative and postoperative
hand therapy program.

Preoperative Program

Preoperative evaluation, establishing rapport and exercise

therapy, is important in that a finger with a poor grade can be
improved [1]. Boyes [2, 3] and Hunter [4] have shown that
the preoperative condition of a finger predicts the result from
two-stage tendon grafting surgery. At their initial examination
at the Hand Rehabilitation Center, patients are classified
according to a system proposed by Boyes and modified by
Hunter:

Hand Therapy, Hand Rehabili-

Evelyn J. Mackin, L.P.T., Director,
tation Center, Ltd., Philadelphia, Pa.

459
460 E. J. MACKIN

Grade 1 (good): Good soft tissues, supple joints and no

significant scarring.
Grade 2 (scar): Deep cicatrix resulting from injury or
previous surgery as well as mild soft-tissue contractures,
which in a few instances may be severe enough to
require preliminary plastic procedures.
Grade 3 (joint): Limitation of passive joint motion, usually
in the proximal interphalangeal joint, sufficient to
require mobilization by traction and dynamic splinting.
Grade 3 patients may show scarring at the tendon bed.
(Those with significant scarring should be classed grade
Ds)
Grade 4 (nerve): Nerve damage with associated trophic
changes, in addition to scarring of the tendon bed and
joint stiffness.
Grade 5 (multiple): Soft tissue scarring or joint changes in
more than one digit, or a combination of injuries in a
single digit of such character that grades 2, 3 and 4 do
not apply; in addition, there may be involvement of the
palm in many cases.
Grade 6 (salvage): Joint stiffness — borderline circulation
and nerve deficits. The finger can be useful to the hand,
however, if reconstructed. Certain fingers may require
amputation rather than reconstruction.

Most candidates for the staged tendon reconstruction have

sustained trauma sufficient to produce a scarred tendon bed
and/or limitation of passive joint motion, scarring and nerve
injury. These would be classified as grades 2 through 6. Patients
in these classes can often be upgraded prior to stage 1 surgery
(pulley reconstruction and Silastic tendon implantation)
through carefully supervised therapy. Therefore a program of
whirlpool, massage, finger trapping, Velcro trapper and web
straps is initiated in this group. Whirlpool is an excellent
preliminary to massage. Massage with lanolin or cocoa butter
softens fingers with contractures or stiffness.
The patient who cannot actively flex his injured finger is
instructed to trap the involved finger with the adjacent normal
finger (Fig. 1). With this method of trapping he is able to
passively flex the finger and therefore increase its pliability. A
THERAPY PROGRAM/STAGED TENDON GRAFTING 461

FIG. 1. Finger trapping.

soft, pliable hand with maximum range of motion is the goal

prior to stage 1 surgery.
Some patients are unable to trap the injured finger with the
adjacent finger perhaps due to intrinsic paralysis, lack of
dexterity or some other factor. These patients may be given a
Velcro trapper (Appendix). The injured finger and the adjacent
normal finger are strapped together to simulate active flexion
(Fig. 2). Whenever the normal finger is flexed, the adjacent
use
injured finger must also come into play. The patient may
ent
this trapper when performing activities that require intermitt
injured
flexion or sustained grip, thereby incorporating the
finger into useful function.
stage
Soft tissue and joint stiffness must be corrected before
finger- pulp to
1. Passive stretching is necessary to improve the
lished by
palmar-crease range of motion and can be accomp
s do not
using a web strap (Appendix) (Fig. 3). Many patient
proxim al inter-
have enough passive flexion at the distal and
web strap. It is
phalangeal joints to be able to use the simple
web strap (Appen dix).
necessary to fabricate a more adaptable
the simpler web
When the passive flexion improves sufficiently,
462 E. J. MACKIN

FIG. 2. Injured finger and adjacent finger are strapped together (A) to
simulate active flexion (B).
THERAPY PROGRAM/STAGED TENDON GRAFTING 468

angeal joint
FIG. 3. Web strap is worn on the distal or proximal interphal
and behind the metacarp ophalang eal joint.

e
strap can be used to increase the passive potential. The distanc
distal palmar crease is
in inches from the finger pulp to the
goal is to increase the
referred to as the passive potential. The
passively
patient’s passive potential (Fig. 4) until he can fully
to stage 2 grafting ; in this
touch the distal palmar crease prior
motion followi ng stage
way we know what to expect in active
2. Measurements are taken and recorde d.
ng. The
Flexion contractures may be improved with splinti
-made thermo plasti c splint,
Joint Jack (Fig. 5A, B); a custom
cylinde r casting should be
such as Aquaplast*; or a removable
of such deform ities is a
prescribed for the patient. Correction
and postop erativ e treatm ent.
desirable goal of both preoperative
of the proximal
When both flexion of the finger and extension
the patient may alternate the
interphalangeal joint are needed,
web strap. The regime n would
extension splint with the flexion
It is also possibl e to alternate
be the same as for the web strap.
Street, Ransey, NJ 07446.
* Aquaplast. WFR Corporation, 68 Birch
464 E. J. MACKIN

FIG. 4. Passive potential.

the program at night. One night the patient may use the web
strap for passive flexion, and the following night he may use the
extension splint. With this program, he will achieve optimum
range of motion in the joint.

Stage 1

When the surgeon is satisfied with the preoperative condi-

tion of the hand, the patient is scheduled for stage 1 surgery. At
surgery the implant is placed in the finger, under the pulleys,
through the palm and into the distal forearm [5-7]. The
implant is sutured distally to the profundus stump or to the
distal phalanx. No proximal juncture is made. This is a passive
gliding implant. An alternate method utilizes the Hunter-
Hausner Passive Tendon Implant* in which the distal attach-
ment is securely fixed to bone, using a metal end device and

*Hunter-Hausner Passive Tendon Implant. Holter-Hausner Interna-

tional, 3rd and Mill Streets, P.O. Box 1, Bridgeport, PA 19405.
THERAPY PROGRAM/STAGED TENDON GRAFTING 465

nonelastic force (B).

FIG. 5. The Joint Jack (A) provides a steady
A466 E. J. MACKIN

screw. This more secure fixation is employed so that before

closing the wound at stage 1, the implant may be more forcibly
pulled proximally to stress weak pulleys that may rupture
during stage 2 training. The implant is grasped at the proximal
end by the surgeon and several kilograms of force is applied to
the pulley system as the finger flexes (Fig. 6). This forceful
flexion of the finger provides the only real opportunity for the
surgeon to assess the mechanics of the finger pulley system
prior to therapy training of the tendon-grafted finger after stage
2. Weak pulleys that rupture or attenuate will require recon-
struction using a tendon graft (Fig. 7). As the surgeon grasps the
tendon and the finger flexes to the distal palmar crease, he gets
an active potential prediction.

Postoperative Treatment
Postoperatively, the hand is encased in plaster for three
weeks to permit organization of the new sheath around the
implant. The wrist is positioned in 30° flexion, the metacarpal

FIG. 6. Before closing at stage 1, the implant is pulled proximally by the

surgeon and the pulley system is carefully analyzed.
THERAPY PROGRAM/STAGED TENDON GRAFTING 467

FIG. 7. Pulley reconstruction.

joints in 60° to 70° flexion and the interphalangeal joints in

slight flexion. Light, protected function is started in the first
week and consists of controlled passive movements and light
trapping. Programmed activity is begun after three weeks.
Whirlpool and massage are instituted. The patient is again
taught to trap the finger to simulate active flexion. Cases of
joint contracture may require K-wire fixation in the operating
room or intermittent splinting as early as the first postoperative
week. Usually by the sixth week, gliding of the implant should
take place without complication.
Patients are carefully managed to prevent synovitis, which
the
may occur when a zealous patient or therapist overexercises
s, if
finger, resulting in a painful, shiny, swollen finger. Synoviti
it occurs, responds to rest, splinting and reduced motion.
About three months is allotted between stages 1 and 2 to
-
allow for optimal healing, softening of the tissues and mobiliza
for good
tion of joints. Prior to stage 2 surgery, we look
the distal
mobilization of joints, trapping of the finger to
supple
palmar crease, full passive range of motion, soft tissues,
468 E. J. MACKIN

joints and a viable gliding system. The patient’s hand should be

graded to its maximum quality before stage 2. To visualize the
location of the tendon implant, the hand is x-rayed at six weeks
and on the day prior to stage 2 replacement surgery.

Stage 2

At stage 2 the implant is replaced with a free tendon graft.

The distal end is attached to the distal phalanx, using standard
techniques such as the Bunnell method of fixation with a
button and pull-out wire; the proximal juncture might be made
to a sublimis or profundus tendon in the distal forearm and
palm. Another carefully fitted dorsal splint is applied to the
patient’s hand. It is most important that the dorsal splint be
fitted properly, with the wrist in 40° flexion and the meta-
carpophalangeal joints in 80° flexion. Adhesive tape should be
applied firmly across the forearm, wrist and palm to ensure that
the patient’s hand will not slip back into the splint, putting
tension on the newly sutured tendon juncture.

Postoperative Hand Therapy

Early motion may be initiated with supervised passive
flexion of the grafted finger, usually at five days (Fig. 8). The
padded dorsal splint prevents sudden forceful extension.
Gently, the patient should passively flex the distal and proximal
interphalangeal joints ten times each, repeating this exercise
three or four times a day. The patient is also permitted to
actively wiggle his finger in the splint. The gauze bandage
around the patient’s finger should be pulled away from the
interphalangeal joints so that it does not offer any resistance to
the graft. With the finger properly positioned and bandaged in
the splint, and after being carefully instructed in early exercises
by the physician and therapist, the patient may begin early light
flexion “like a butterfly” and extend the finger within the
limits of the dorsal splint. Early controlled flexion is necessary
to minimize edema, prevent the formation of adhesions, keep
the finger soft and promote the return of optimum finger
flexion.
In selected cases of two-stage tendon reconstruction the
surgeon may opt to incorporate rubber band traction into the
postoperative program. The rubber band may be attached to the
THERAPY PROGRAM/STAGED TENDON GRAFTING 469

FIG. 8. Passive flexion of the grafted finger.

fingertip in the operating room or at the first postoperative

visit. One advantage of the rubber band traction is that it
facilitates tendon and joint movement without requiring active
pull on the flexor tendon. Another advantage is protection
against sudden injury. Should the patient jerk the hand during
sleep, or fall, the rubber band will protect the juncture from the
stress of extension.
At surgery a nylon suture is put in the tip of the fingernail
so that a rubber band, active training program may be initiated
early in the postoperative period. We prefer to wait until day 1
when the patient comes to therapy so that the quality,
y
positioning and tension of the rubber band can be accuratel
established.
very
When the finger is flexed and at rest, there should be
rubber band. With the hand careful ly
little tension on the
and with light tension on the rubber
positioned in the splint
and permit the
band, the patient may actively extend the finger
470 E. J. MACKIN

rubber band to passively flex the finger a couple times each

hour. In addition, gentle passive flexion of the proximal
interphalangeal and distal interphalangeal joints is carried out
ten times, three or four times a day.
In instances where the nylon suture has not been applied to
the fingernail at surgery, a sling of moleskin may be used to
provide rubber band traction around the button and pull-out
wire. A segment of moleskin about 3 inches long and one-half
inch wide is folded in half and an eyelet is punched through at
the folded end of the moleskin. An ‘‘S’’ hook, made from a
paper clip, is hooked through the eyelet opening and an elastic
band is attached from it to a safety pin on the volar surface of
the forearm dressing or (when the protective splint is no longer
required) to a wrist cuff. Tincture of benzoin applied to the
finger will help adhere the moleskin.
Constant supervision and encouragement by the surgeon
and hand therapist are vital. The surgeon must inform the
therapist how much tension the tendon and the pulleys will
tolerate. The surgeon must initiate the early motion, since it is
the surgeon who knows the quality of the tendon. Only a
complete understanding of the tendon graft procedure, as well
as knowledge of the condition of the tendon and the pulleys,
will give the therapist a safe guide to the postoperative phase of
early motion. Patients should be seen by the surgeon once a
week and by the therapist three times a week. Active tendon
pull-through should be carefully checked at each visit.
When full excursion of the tendon graft occurs within the
first three to four weeks postoperatively, it indicates the
formation of minimal adhesions. In such a case the juncture is
under greater risk of rupture if it is stressed. When the tendon
graft is sliding well, and weekly measurements taken by the
surgeon and therapist indicate rapid improvement in active
flexion to the distal palmar crease, resistive exercise should not
be permitted before the eighth postoperative week. These
patients may require intermittent splinting in the dorsal splint
for six to eight weeks to protect the juncture from excessive
stress.
Six to eight weeks after stage 2 surgery, the button suture is
removed. The protective dorsal splint is discarded at this time
and the patient is ready to begin a more active exercise
THERAPY PROGRAM/STAGED TENDON GRAFTING 471

program. When the button suture is removed, hydrotherapy

may be started again. Exercising in the whirlpool will facilitate
motion. Hands that have shown stiffness prior to stage 1 may
require some softening again with lanolin massage. Besides
active and passive flexion of the distal and proximal inter-
phalangeal joints, the patient will now begin active wrist
range-of-motion and is encouraged to perform light activities of
daily living.
Individuals recovering from lengthy hand disabilities need to
restore their muscle power before returning to work. Strength-
ening and resistive activities, when permitted by the surgeon,
are started carefully and increased in intensity and endurance as
the patient progresses.
At eight weeks after surgery, besides active and passive
exercise, the patient may begin light, supervised woodworking
(sanding, filing, etc.) and progressive weight-resistance exercises
to strengthen grip. Heavy resistive exercises are restricted for
three months.
Good results following two-stage tendon reconstruction
may be attained when there is close teamwork between the
surgeon, the hand therapist and the patient. Each patient is an
individual; the postoperative management of two-stage tendon
grafting must be flexible and adapted to each patient’s surgical
procedure and the decision of the surgeon. Then will come the
exciting results!

Special Considerations

Motion Limiting Adhesions

It must be remembered that each patient is an individual

d and
and postoperative treatment must always be modifie
. If active flexion
changed according to the patient’s progress
by the surgeon
improves steadily at each week of reevaluation
If adhesions are
and therapist, then the program is not changed.
d from the dorsal
limiting motion, the patient will be remove
and a slightly more
splint earlier, i.e. at four to six weeks,
d earlier, beginni ng
aggressive exercise program will be initiate
472 E. J. MACKIN

with gentle active finger blocking and then progressing to

resistive exercise with the Bunnell wood block.

Bunnell Wood Block

The Bunnell wood block is one-fourth inch thick and about
the size of a cigarette pack. It provides a means of training full,
active power ranges of the distal and proximal joints of the
finger. Patients are carefully instructed in the use of the wood
block when exercising. They are told to keep the metacarpo-
phalangeal joint firmly against the block by supporting it with
the fingers and thumb of the other hand when flexing the
proximal interphalangeal joint. Similarly, they must block the
metacarpophalangeal and proximal interphalangeal joints when
flexing the distal interphalangeal joint. Blocking facilitates
isolated sublimis arid profundus action.

Proximal and Distal Interphalangeal

Contractures
Early attention to beginning interphalangeal flexion con-
tractures is of primary importance. When the surgeon and the
therapist are alerted to a proximal interphalangeal flexion
contracture occurring, passive extension of the joint may be
begun as early as one week postoperatively. No ‘tendon
tension’’ extension may be initiated. Tension is taken off the
tendon by flexing the adjacent joint. With the dorsal splint
supporting the wrist and metacarpophalangeal joints in flexion,
the therapist may support the metacarpophalangeal joint in
flexion and gently extend the proximal interphalangeal joint to
improves extension. If the distal interphalangeal joint shows a
beginning contracture, the therapist may support the meta-
carpophalangeal and proximal interphalangeal joints in flexion
and gently extend the distal interphalangeal joint. Passive
extension done by this technique removes tension from the
tendon juncture. The patient should be instructed in a special
home program of passive extension exercises carried out by this
technique within the dorsal splint.

Distal Interphalangeal Flexion Contractures

A persistent distal interphalangeal flexion contracture (Fig.
9A) may be corrected with removable cylinder casting (Fig.
THERAPY PROGRAM/STAGED TENDON GRAFTING 473

wa

ture. (B) Removable

FIG. 9. (A) Distal interphalangeal flexion contrac
casting. (C) The cast may be remove d to exercise the grafted
cylinder
finger.
474 E. J. MACKIN

9B). The cast may be worn during the day, removed only for
exercise (Fig. 9C) and wor during the night to maintain
extension. Casting has also been used successfully after tendon
repairs. Used correctly, casting is anontraumatic way of gaining
extension.

Superficialis Finger
A superficialis finger implant and a later graft to the base of
the middle phalanx and distal arthrodesis constitute a good
solution in a grade 6 case. At stage 1 the implant is securely
fixed to the base of the middle phalanx by suture or a screw
fixation device. The distal phalanx is either tenodesed or
arthrodesed. At stage 2 reconstruction of the superficialis finger
the same procedures are followed as for tendon grafting to the
distal phalanx. Postoperative therapy is directed to the proximal
interphalangeal joint, with good results. The training program
becomes simplified and the result more predictable.

Pulley Reconstruction
At stage 1 surgery the surgeon may have to rebuild ruptured
pulleys. He also will apply traction to the prosthesis where
pulleys seem to be satisfactory, to determine the active
potential. If the finger does not fully flex to the distal palmar
crease, it may be necessary for the surgeon to modify the pulley
system or to accept the reduced active potential as a final result
after stage 2. This predicted potential is measured and recorded.
Stage 1 postoperative therapy follows the same procedure as
stage 1 without pulley reconstruction. Since this is a passive
gliding implant, there is no tension on the pulley. In stage 2
postoperative therapy, when the A-2 pulley has been recon-
structed, it becomes necessary to fabricate a thermoplastic ring
for the patient. With the ring supporting the pulley, the patient
may begin early motion without putting stress on the pulley
(Fig. 10).

Appendix

Trapper
A trapper (Fig. 11) may be fabricated as follows: The
posterior surface of the Velcro hook is laid on the anterior
THERAPY PROGRAM/STAGED TENDON GRAFTING 475

FIG. 10. Thermoplastic ring to support reconstructed pulley.

FIG. 11. Velcro trapper.

476 E. J. MACKIN

surface of the Velcro loop. Stitch together in the middle. Fold

backward so that the hook strips face each other and the
posterior side of the loop strips face each other. Stitch again on
both sides of the seam.

Web Strap
A web strap (Fig. 12) may be fabricated from 1-inch lamp
wick and a smali buckle. Lamp wick is preferable to stiffer
webbing because it is soft and fits snugly and comfortably
around the joints. The strap should be at least 12 inches long. In
some instances, depending on the amount of passive flexion and
the size of the patient’s hand, it may be necessary to make it 15
inches or more in length. The strap is worn over the distal or
proximal interphalangeal joint, depending on which joint is to
be stretched, and behind the metacarpophalangeal joint. The
length of time the strap is worn is gradually increased from 15
minutes three times a day to two hours three times a day. It can
be worn longer. The most gain in passive flexion comes from
wearing the strap snugly for long periods of time. It is the long,
steady stretch that improves the range of motion. It is especially
helpful if the patient wears it during the night while sleeping. It
does not have to be worn as snugly at night, when it becomes a
retaining splint to maintain the gain made during the day. The

FIG. 12. Web strap.

rN i

ed passive flexion.
FIG. 13. Adaptable web strap provides graduat
478 E. J. MACKIN

therapist should emphasize that the strap is to be removed if it

causes any pain or discomfort.

Adaptable Web Strap

Fabrication of the adaptable web strap (Fig. 13) is as
follows: Materials required to construct the more adaptable web
strap are 1-inch-width Velcro hook and loop (approximately 24
inches long), a 1-inch buckle and a 1-inch “D” ring. This more
adaptable passive flexion strap is very useful when the proximal
and distal interphalangeal joints are extremely limited. It is
comfortable, easily adjusted and can be worn as a night splint.

References

1. Mackin, E.J. and Maiorano, L.: Postoperative therapy following staged

flexor tendon reconstruction. Jn Hunter, Schneider, Mackin and Bell
(eds.): Rehabilitation of the Hand. St. Louis:C. V. Mosby Co., 1978,
pp. 247-261.
2. Boyes, J.H.: Flexor tendon grafts in the fingers and thumb — An
evaluation of end results. J. Bone Joint Surg. 32A:489, 1950.
3. Boyes, J.H.: Evaluation of results of digital flexor tendon grafts. Am. J.
Sirs, SOS
Is WI1G) WH.
4. Hunter, J.H. and Jaeger, S.H.: Tendon implants: Primary and second-
ary usage. Symposium on Replantation and Reconstructive Micro-
surgery. Orthop. Clin. North Am. 8(2):473-489, 1977.
5. Hunter, J.M. and Salisbury, R.E.: Flexor-tendon reconstruction in
severely damaged hands. J. Bone Joint Surg. 53A(5):829-858, 1971.
6. Mackin, E.J. and Hunter, J.M.: Pre- and Post-Operative Hand Therapy
Program for Patients with Staged Gliding Tendon Prosthesis (Hunter
Design). Philadelphia: Hand Rehabilitation Foundation, 1977, p. 1-2.
7. Hunter, J.M.: Staged flexor tendon reconstruction. Jn Hunter,
Schneider, Mackin and Bell (eds.): Rehabilitation of the Hand. St.
Louis:C. V. Mosby Co., 1978, pp. 235-246.

Self-Evaluation Quiz

1. Most candidates for tendon reconstruction have good soft

tissues, supple joints and no significant scarring.
a) True
b) False
2. The preoperative condition of a finger predicts the result
from two-stage tendon grafting surgery.
a) True
b) False
THERAPY PROGRAM/STAGED TENDON GRAFTING 479

3. Patients with a poor-grade finger can often be upgraded

prior to surgery through carefully supervised therapy.
a) True
b) False
The Hunter-Hausner tendon implant is a passive gliding
implant, which means that its purpose is to assist organiza-
tion of a new tendon bed prior to tendon grafting.
a) True
b) False
Synovitis is necessary to organize the sheath around the
implant.
a) True
b) False
In most instances, the implant is replaced with a free tendon
graft three weeks after implantation at stage 1.
a) True
b) False
At stage 2 surgery (replacement of the implant with a free
tendon graft) proper positioning of the hand in the dorsal
splint is of prime importance to prevent tension on the
newly sutured tendon juncture.
a) True
b) False
Early motion to enhance “tendon excursion” may be
initiated within five days postoperatively.
a) True
b) False
When full excursion of the tendon graft occurs within the
first three to four weeks, it indicates that the patient heals
quickly.
a) True
b) False
iO Tendon training has become simplified in that guidelines are
now established for exact postoperative management of
tendon reconstruction.
a) True
b) False

Answers on page 527.

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 Wrist Arthrography
Robert L. Hamm, M.D.

Objective
The purpose of this discussion is to present the wrist
arthrogram findings of a number of clinical entities and to
indicate the clinical usefulness in these same entities.

Wrist arthrography is an easily performed examination

which allows evaluation of synovium, interosseous ligaments,
cartilage and other features not seen on plain films. This
discussion addresses primarily the clinical usefulness of wrist
arthrography and secondarily the contribution of wrist arthrog-
raphy to the understanding of the pathogenesis of certain
disorders. Our series of over 300 wrist arthrograms extends over
a four-year period and includes an earlier published study of
wrist arthrograms in 100 normals [1]. This control series has
been central to our interpretations and conclusions as to the
clinical applications of wrist arthrography.

Technique

Under sterile conditions and with local anesthesia, the

radiocarpal joint is entered dorsally with a 22-gauge, 1’4-inch
needle just distal to the radius. After aspiration of any fluid
present, approximately 2 cc of meglumine diatrizoate is
injected. A test injection of one or two drops under fluoro-
scopic control, before injection of the full amount, can be used
to prevent false injections. After brief flexion and extension
motions, posteroanterior, oblique and lateral films are obtained.
Optimum studies require films be taken shortly after contrast
injection as synovial detail is soon obscured by absorption of
dye.

Robert L. Hamm, M.D., Radiologist, Providence Hospital, Washington,

D.C.
A81
482 R. L. HAMM

Anatomy

The wrist has the following joints or compartments:

radiocarpal, inferior radioulnar, midcarpal, carpometacarpal and
pisiform- triquetral.
Radiocarpal (Figs. 1 and 2). The navicular, lunate and
triquetral bones and their interosseous ligaments constitute the
distal margins of the radiocarpal joint. The proximal border is
composed of the radius and the triangular cartilage. The
prestyloid recess (Figs. 1 and 2) is an ulnar extension of the
radiocarpal joint that has been variously described as a
diverticulum, bursa or recess. It may approach the anterior
aspect of the ulnar styloid, just reach it or envelope it. A major
contributer to the distal boundary and neck of the recess is the
meniscus. The prestyloid recess is a key arthrographic landmark,
and is always present in the normal. While varying greatly in size
among individuals, a high degree of symmetry between the
recesses of the same individual has been noted in our series.

M1OCAR PAL

PISIFoRM -
TRIQUETRAL
mewiscus
PRESTYLOIO
RECESS
TRIANGULAR
CARTILAGE

RADIOULNVAR

FIG. 1. Major wrist compartments and their boundaries.

WRIST ARTHROGRAPHY 483

FIG. 2. Normal wrist arthro-

gram. Contrast is localized to
the radiocarpal compartment.
The prestyloid recess en-
velops the tip of the ulnar
styloid.

Deviation from this symmetry in itself suggests pathology. The

prestyloid recess is a sensitive and early indicator in certain
disease processes, especially those which are primarily synovial,
the
such as rheumatoid arthritis. Corrugation or obliteration of
prestyloid recess may be the first finding. The intimate relation
by
of the prestyloid recess to the ulnar styloid has been shown
why styloid erosions are among the
Resnick [2] to explain
joint
earliest plain-film findings. Another type of radiocarpal
al volar excrescen ces, has been noted in
extension, radiocarp
cases (Figs. 3 and 4). They also can be early
about 50% of our
indicators of synovial pathology.
inferior
Inferior Radioulnar (Figs. 1, 3 and 4). The L-shaped
rpal by the
radioulnar joint is separated from the radioca
triangular cartilage.
t is separated
Midcarpal (Figs. 1 and 5). This compartmen
the proximal carpal
from the radiocarpal compartment by
bones and their interosseous ligaments.
FIG. 3. Radiocarpal volar ex-
crescences (arrows), a normal
finding, are well developed in
this patient. Contrast is pres-
ent in the inferior radioulnar
compartment, indicating an
Opening in the triangular car-
tilage.

FIG. 4. Lateral view of ar-

throgram in Figure 3. Arrow
identifies radiocarpal volar
excrescences. Contrast in the
inferior radioulnar compart-
ment is also demonstrated.
FIG. 5. Contrast is present in
the midcarpal and radioulnar
compartments, as well as the
injected radiocarpal compart-
ment.

Patterns of Pathology

Compartment Communication. Contrast injected into the

radiocarpal compartment classically remains within this joint.
The most easily recognized abnormality is contrast in the
radioulnar or midcarpal compartments. Compartment com-
munication has been reported in a wide variety of disorders,
including rheumatoid arthritis [3], gout [1], ankylosing spon-
dylitis [4], neuropathic disease [4] and trauma [5]. The signifi-
ex-
cance of compartment communication has been debated
to its presence in a percentag e of
tensively, especially in regard
normals.
Trauma. Tears of the triangular fibrocartilage separating the
as a
radiocarpal and radioulnar joints have long been considered
In 1956, Colema n [6] found at
possible cause of disability.
in four patients , felt to be due
surgery tears of the fibrocartilage
and tender-
to hyperextension rotational strain. A painful click
[4] describ ed 4 such tears in a
ness has followed. Kessler
486 R. L. HAMM

control autopsy series of 60 wrists, but found 11 tears in 24

wrists (by arthrography) of patients with a history of ‘“‘strain”’
and disability. In our series, in 14 patients with a history of old
trauma, a significant age-adjusted correlation of radiocarpal-
radioulnar communication was found. All of these patients were
over 40 years of age. Of six patients with recent trauma (less
than three months), radiocarpal-radioulnar communication was
demonstrated in three. While a statistical relationship between
wrist trauma and radiocarpal-radioulnar communication is felt
to be established, the strikingly high communication incidence
of 35% in our control populations indicates this finding to be of
little clinical significance in an individual case.
Age, Occupational Activity. In a previous publication [1],
we found a statistically significant increase in radiocarpal-mid-
carpal communication with increasing age and with a history of
increased occupational activity. This suggests a ‘‘wear and tear”
mechanism. No such increased incidence in radiocarpal-radiou-
Inar communication was noted.
Rheumatoid Arthritis. Several series have documented an
increase in compartment communication in rheumatoid arthri-
tis [1, 3, 4]. In 60 patients with a diagnosis of rheumatoid
arthritis, Harrison [3] found 70% to have communication
between the radiocarpal and midcarpal joints, and similarly a
70% incidence of communication between radiocarpal and
inferior radioulnar joints. In our series of ten patients with
definite rheumatoid arthritis, 20% were found to have mid-
carpal extension alone, 45% had radioulnar extension alone and
15% had three-compartment communication. Only 20% ex-
hibited the classical normal appearance of radiocarpal localiza-
tion. However, in our control series of 200 arthrograms,
radiocarpal-midcarpal communication was found in 27%, radio-
carpal-radioulnar communication was noted in 15% and 20%
exhibited three-compartment communication [1]. We conclude
that compartment communication is of little diagnostic signifi-
cance in an individual case.
Gout. In our 15 patients with a diagnosis of gout, 43% had
radiocarpal-midcarpal extension, 17% had radioulnar extension,
and 20% had three-compartment communication. The radio-
carpal-midcarpal extension was statistically significant against
our control series, but radioulnar extension was not. Radioulnar
WRIST ARTHROGRAPHY 487

extension was significantly increased in rheumatoid arthitis,

suggesting it to be a more aggressive synovitis than gout.
Lymphatic Visualization. Visualization of lymphatics with
wrist arthrography has been described as a frequent finding in
rheumatoid arthritis (Fig. 6): 42% in Resnick’s series [4], 33%
in Harrison’s series [3] and 50% in Trentham’s series [1]. The
precise mechanism is unclear, but increased synovial perme-
ability, block of some lymphatic channels and hyperplastic
lymphatic response have been suggested. In our series, 3 of 15
patients with gout were found to have lymphatic visualization.
Occasional reports of this finding in Driller disease [4], trau-
matic arthritis [4] and degenerative conditions [5] have ap-
peared. However, in our series, which includes 6 acute wrist
injuries, 14 old wrist injuries and over 240 wrist arthrograms in
patients over the age of 40 (many with obvious x-ray evidence
of degenerative changes), no lymphatic visualization has been
found, except in gout and rheumatoid arthritis. We have not
performed arthrography in ankylosing spondylitis or Driller

FIG. 6. Contrast is demon-

strated in a lymphatic in a
patient with rheumatoid
arthritis.
A88 R. L. HAMM

disease. While not specific, we feel that lymphatic visualization

is highly suggestive of granulomatous arthritis.
Corrugation. Corrugation is the arthrographic presentation
of synovial hypertrophy or irregularity. In contrast to such
findings as lymphatic visualization and compartment communi-
cation, the criteria for corrugation are more difficult to define,
and appear to have varied somewhat between some series. In
fact, corrugation appears as a granularity or nodularity ranging
from fine to coarse (Fig. 7). At the margins this may appear as a
saw-tooth pattern. This same corrugation may be seen in tendon
sheaths which communicate with contrast-filled wrist compart-
ments. Corrugation may often be seen best in the prestyloid
recess. However, synovial hypertrophy may occlude the opening
of the prestyloid recess, resulting in arthrographic obliteration.
Some mild undulation or localized granularity may be found in
normal arthrograms. Our criteria for a diagnosis of synovial
corrugation include the requirement that the pattern be
generalized or involve multiple areas. Resnick [4] found cor-
rugation in 92% of his series of rheumatoid arthritis, and
Harrison [3] found this to be present in 90%. Our finding of

FIG. 7. Synovial corrugation is demonstrated in early rheumatoid arthritis

in a patient in whom no bony changes could be detected. Contrast is
present in the radioulnar compartment.
WRIST ARTHROGRAPHY

FIG. 8. Contrast is demon-

strated in an extensor tendon
sheath.

corrugation in only 50% of ten patients with rheumatoid

arthritis is probably due to our requirement that corrugation be
present in multiple areas. However, using this strict criterion, we
found no corrugation in our series of 200 normal wrist
arthrograms [1]. We have not found corrugation in cases of
acute or old trauma, nor in cases of severe degenerative changes.
We did find corrugation in 20% of 15 patients with gout.
Tendon Sheath Opacification. Opacification of tendon
sheaths with injectio n of contrast into the radiocarpal joint
(Fig. 8) was found in 23% of Harrison ’s series [3] of 60 patients
with rheumatoid arthritis and in 28% of Resnick’ s series [7] of
findings of
AO patients with rheumatoid arthritis. However, our
200 normal
tendon sheath opacification in 6% of a series of
appears to limit the diagnost ic signific ance of
wrist arthrograms
this finding.
References
Wrist arthrography: Review
1. Trentham, D., Hamm, R. and Mase, A.:
and comparison of normals , rheuma toid arthritis and gout patients.
Semin. Arthritis Rheum. 5:105-120, Nov. 1975.
490 R. L. HAMM

2. Resnick, D.: Rheumatoid arthritis of the wrist: Why the ulnar styloid?
Radiology 112:29-35, July 1974.
3. Harrison, M.O., Freiberger, R. and Ranawat, C.: Arthrography of the
rheumatoid wrist. Am. J. Roentgenol. Radium Ther. Nucl. Med.
112:480-486, July 1971.
4. Resnick, D.: Arthrography in the evaluation of arthritis disorders of the
wrist. Radiology 113:331-340, Nov. 1974.
5. Kessler, I. and Silverman, Z.: An experimental study of the radiocarpal
joint by arthrography. Surg. Gynecol. Obstet. 112:33-40, Jan. 1961.
6. Coleman, H.: Tears of the fibrocartilage disc of the wrist. J. Bone Joint
Surg. 38B:782, 1956.
7. Resnick, D.: Rheumatoid arthritis of the wrist. Med. Radiog. Photog.
52:50-88, 1976.

Bibliography
Haage, H.: Arthrographie des Handgelenks. Fortschr. Med. 89:841-843,
1971.
Lewis, O., Hamshere, R. and Bucknill, T.: The anatomy of the wrist joint.
J. Anat. 106:539-552, 1970.

Self-Evaluation Quiz

1. Synovial corrugation is found in which of the following?

a) Acute trauma
b) Gout
c) Degenerative joint disease
d) Asmall percentage of normals
2. Lymphatic visualization is not found in which of the
following?
a) Degenerative joint disease
b) Gout
c) Rheumatoid arthritis
d) Ankylosing spondylitis
3. Which of the following is not increased in frequency in
rheumatoid arthritis?
a) Radiocarpal localization
b) Synovial corrugation
‘c) Lymphatic visualization
d) Radiocarpal-radioulnar communication
4, In the diagnosis of rheumatoid arthritis, which is the most
important finding?
a) Tendon opacification
b) Synovial corrugation
WRIST ARTHROGRAPHY 491

c) Radiocarpal-radioulnar communication
d) Radiocarpal-midcarpal communication
5. In gout, which of the following is true?
a) Increased frequency of radiocarpal-midcarpal com-
munication
b) Increased frequency of radiocarpal-radioulnar communi-
cation
c) Increased frequency of three-compartment communica-
tion
d) All of the above
6. Which ot the following is untrue about tendon opacifica-
tion?
a) Can be found in normals
b) Increased frequency in degenerative joint disease
¢) Increased frequency in gout
d) Increased frequency in rheumatoid arthritis

Answers on page 527.

 Infections of the Hand
James W. Strickland, M.D.

Objectives
1. To recognize the most common infections which
involve the hand and the organisms which cause them.
2. To provide clinical correlation of the signs, symptoms
and diagnosis of these infections.
3. To review the methods of treatment of the various hand
infections, including supportive and antibacterial treat-
ment.
4. To provide a brief description of some of the more
uncommon infections of the hand and to discuss causes
of chronicity or failure of treatment.

History

Prior to the advent of antibiotics, hand infections were

often both devastating to function and life-threatening. The
first major hand surgery book in this country was written by
Allen B. Kanavel of Chicago and dealt exclusively with the
difficult problems of infection of the hand [1]. First printed in
1912, this book was published in six editions through 1939 [2],
and emphasized careful diagnosis, fascial spaces, proper in-
cisions and correct positioning of the hand following infection.
An important additional contribution was made in 1963 with
the publication of a small book entitled The Infected Hand by
David A. Bailey [3], based on his experience in the Hand Clinic
with
at University College Hospital in London (in association
Mr. R. S. Pilcher). Important refinements in surgical approaches

e Professor of
James W. Strickland, M.D., F.A.C.S., Clinical Associat
Indiana Universi ty Medical School; Chief, Hand
Orthopaedic Surgery,
Chief, Section of
Surgery Rotations, Indiana University Medical Center;
St. Vincent Hospital,
Hand Surgery, Department of Orthopaedic Surgery,
Indianapolis, Ind.

493
494 J. W. STRICKLAND

to more common hand infections were illustrated in this book.

A similar monograph entitled The Care of Hand Infections was
published in 1970 by Joan Snedden [4] from the Royal
Hospital in Sheffield and provided a concise review of the
differential diagnosis of hand infections, with important consid-
erations with regard to treatment. An important review article
entitled “Common and Uncommon Infections of the Hand”
was prepared by Ronald L. Linscheid and James UH.
Dobyns [5]. This article summarized the most current tech-
niques in the management of hand infections and emphasized
the identification and treatment of recently isolated organisms.
Numerous additional articles have provided useful information
with regard to the management of specific infectious entities in
the hand [6-38].
There can be no doubt that there have been enormous
strides in the overall level of recognition and treatment of hand
infections in recent years. Although these conditions no longer
are seen with the frequency or potential morbidity as they were
in the past, they still must be appreciated by primary care
physicians, emergency physicians and hand surgeons if proper
diagnosis and treatment is to be achieved.

Organisms

Table 1 contains a list of the most common bacterial viral

and fungal organisms involved in hand infections. The impor-
tance of these specific organisms will be studied as specific
clinical conditions are considered.

General Considerations

There can be no question that the concern for potential loss

of hand function has led to more frequent hospitalization with
the use of intravenous antibiotics in the early stages of hand
infection. The time-honored regimen of rest, elevation, im-
mobilization and frequent evaluation remains as important
supportive measures in the management of these conditions,
and there has recently been considerable emphasis on early
mobilization techniques. Hot and cold applications to the area
of hand infection have been largely discontinued as ineffective.
The correct use of the wide variety of antibiotic medica-
tions available is extremely important in the proper manage-
HAND INFECTIONS 495

Table 1. Common Organisms and Infections

Bacterial
Most Common: Staphylococci
Streptococci
Pseudomonas
Proteus
Others: Mycobacterium tuberculosis
Atypical mycobacterium
Anthrax
Erysipeloid
Gonorrhea
Pasteurella multocida
Eikenella corrodens
Haemophilus influenzae
Brucellosis

+ Viral
Herpes simplex
Herpes zoster
Cat scratch fever
Vaccinia
Warts
Rabies
ORF

Fungus
Sporotrichosis
Blastomycosis
Ring worm
Coccidioidomycosis
Onychomycosis
Maduromycosis
Nocardiosis
Actinomycosis
Candida albicans
Geotrichum candidum

Anaerobes
Clostridium
Bifidobacterium
Actinomyces
Fusobacterium
Bacteroides
Lactobacillus
Eubacterium
Peptococcus
Veillonella
Bacterium melaninogenicus
ee
SE
(ey
496 J. W. STRICKLAND

ment of the infected hand. Bacteriologic identification of the

offending organism with appropriate sensitivity studies may
provide invaluable information with regard to those agents
which would be most effective. Careful consideration must be
given to choosing the best method of antibiotic delivery in
order to provide blood levels consistent with the therapeutic
requirements presented by a given infection. Although organism
recognition and sensitivity studies are mandatory in the
management of hand infections, certain empiric selections may
be made and are helpful in initiating therapy prior to the results
of these identification techniques. A list of some of the
antibiotics which have proven most effective against gram-
positive, gram-negative and mixed infections is provided in
Table 2. It is important to note that penicillin has not been
shown to be an effective antibiotic in the initial management of
infections of the hand, particularly those seen primarily in the
emergency room, in which a high predominance of penicillin-
resistant staphylococci has been found. It is hoped that this fact
has now been recognized by most emergency and primary care
physicians and that antibiotics more effective against these
organisms are being employed.
The surgical drainage of abscesses, removal of foreign bodies
and sequestered bone, and debridement of necrotic tissue
conducive to infection all remain as important techniques which
may be utilized by those managing the patient with an infected
hand. An understanding of the intricate anatomy of the hand,

Table 2. Antibiotics

Empiric Selections
Gram-Positive: Methicillin
Oxacillin
Cephalosporin
Erythromycin
Clindamycin
Gram-Negative: Gentamicin
Kanamycin

Mixed- Oxacillin or
Cephalosporin
+

Gentamicin
HAND INFECTIONS 497

with recognition of the anatomic spaces described by Kanavel,

is important before surgical intervention is undertaken. Proper
timing, incision placement and postoperative management must
be carried out not only to assure the prompt resolution of the
infectious process, but also to prevent additional injury to
underlying tissues.

Specific Hand Infections

The following is a description of the clinical features of a

number of common hand infections with treatment considera-
tions.

Pulp Abscess (Felon) (Fig. 1)

Although less frequently seen than in previous years, the
pulp abscess remains as a fairly common hand infection, usually
occurring four to five days following a puncture wound to the
digital pad. The organism involved is most frequently Staphy-
lococcus, and the distal phalanx will develop a throbbing pain
on its volar surface with a tender pulp. The digital pad will
become progressively warm and erythematous, and in the late

ng puncture wound. (A)

FIG. 1. Acute pulp abscess (felon) followi
. (B) Appearance after
Appearance of fluctuant pulp of the distal phalanx
of wound edges. Satisfactory resolution
direct drainage and ellipse
followed.
498 J. W. STRICKLAND

stage pus may become visible. Following the advice of Bailey, a

direct approach to the abscess is carried out after a small probe
has been used to identify the area of maximum intensity.
Efficient drainage by direct incision avoids the problems
inherent in the midlateral or fish-mouth approaches, which
often result in a residual depressed and tender scar. An ellipse of
skin should be removed at the incision site to facilitate
continued drainage and obviate the necessity for drains. One
should be wary of the complication of osteitis or osteomyelitis
of the distal phalanx, and chronic drainage following decom-
pression should alert one to this complication.

Cellulitis, Lymphangitis and

Epidermal Abscesses (Fig. 2)

Within 10 to 12 hours of a pricking injury, friction injury or

sometimes following unknown epidermal insults, the hand may
become painful or tender, and the patient may experience
increased temperature. Examination will reveal an area of
warmth and erythema, occasionally with forearm streaking or

FIG. 2. Epidermal abscess of distal palm following chronic friction from

garden hoe handle.
HAND INFECTIONS 499

blister formation. Epidermal abscesses may be present, and a

diffuse erythematous area without abscess formation may
indicate cellulitis. The presence of forearm streaking may
represent a streptococcal infection, and black or green tissues
may be indicative of a Pseudomonas infection. Other organisms
involved in this type of generalized soft tissue infection may be
staphylococci or a mixture of bacteria, or even herpes.
The appropriate treatment for these conditions is rest,
elevation, the use of appropriate antibiotics and the unroofing
of blisters, particularly when they harbor purulent material.
Complications include necrosis of local skin.

Paronychia (Fig. 3)
Swelling, erythema or pus accumulation around the periph-
ery of the nail is indicative of a paronychia, and usually results
from a small hangnail or other nail fold lesion. The offending
organisms are often mixed, and it is important to observe these
lesions in an early stage as injudicious incisions prior to abscess
formation may complicate the situation. An epionychial in-

FIG. 3. Fluctuant paro-

nychia of radial aspect of
the distal phalanx of the
thumb.
 500 J. W. STRICKLAND

cision, or partial or complete nail excision, may be necessary

after pus formation. Complications of this condition include
nail bed damage and osteitis, and the patient should be made
aware that even with a resolving paronychia there may be a
chronic reddening around the nail margin for a number of
months.

Web Abscess and Deep Palmar

Abscesses (Fig. 4)
Puncture wounds in the palm or interdigital web may result
in deep abscess formation within two to three days of the
injury, with Staphylococcus frequently being the offending
organism. A deep throbbing pain with subtle swelling is often
found, and a brawny, erythematous, tender area over the
abscess is often present. Occasionally a “collar button” situ-
ation may exist with a blister overlying a small perforation to
the deep abscess. Incision and drainage are the applicable

FIG. 4. Palmar blister abscess overlying and communicating with thenar

space abscess.
HAND INFECTIONS 501

procedures when there has been abscess formation, with the

wound left open and provision made for continued drainage,
either by means of wound enlargement or the use of a small
drain. The use of appropriate antibiotics, together with im-
mobilization and elevation, is indicated, and the possibility of
suppurative tenosynovitis is a complication of this type of
infection.

Acute Suppurative Tenosynovitis (Fig. 5)

Following a midline volar puncture wound of a finger, acute
suppurative tenosynovitis may develop with purulence located
within the flexor tendon sheath. Streptococcus and Staphylo-
coccus are the most frequent organisms involved in this
condition, with the cardinal signs of tendon sheath infection as
described by Kanavel remaining valid to this day. Specifically,
swelling of the digit, with tenderness over the digital sheath, a
posture of digital flexion and pain with extension are pathog-
nomonic of suppurative tenosynovitis. Early treatment should
consist of a limited incision and drainage with sheath irrigation
through proximal and distal transverse incisions. When the
infection is more extensive and involves the flexor tendons,
then wide incision and drainage with debridement are indicated.
If there has been tendon necrosis or slough, it will be necessary
to excise the involved tendon or tendons before the infectious
process can be controlled. Provisions for early motion must be
made to prevent digital stiffness or tendon adherence.

Pyogenic Arthritis (Acute)

A cut or puncture wound directly over a joint is frequently
organisms
the cause of pyogenic arthritis, although the infecting
is usually one to
may travel via the bloodstream. The onset
ms have been
three days after injury, and numerous organis
processe s. Painful
cultured from the joints involved with these
and drainage,
swelling over a joint, often with limited motion
are usually present.
and some degree of adjacent cellulitis
incision and drainage ,
Treatment should consist of immediate
d joint is often
and at least a partial closure of the involve
is recommended.
indicated. The use of appropriate antibiotics
of this entity.
Articular destruction is the complication
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HAND INFECTIONS 503

Carbuncle (Boil) (Fig. 6)

Local cellulitis, edema and a blister that undergoes separa-
tion and slough are characteristic of a carbuncle, with staphyl-
ococci being the most frequent organisms involved. Pain or
swelling of the hand or fingers will result and early treatment
should consist of removal of the dead cuticle. Late treatment
consists of removal of all sloughed tissues. Organism identifica-
tion and the appropriate antibiotic management are important.

Herpetic Whitlow
Medical personnel in frequent contact with the oral, trachial
or pharyngeal secretions of patients may often develop herpetic
infections in their digits, with the thumb, index and long fingers
of the dominant hand being the most commonly infected. This
condition, referred to as herpetic whitlow, presents with pain in
the affected digit with erythema in the paronychial or pulp
areas. Early vesicle formation may coalesce into bullae, or

l phalanx.
FIG. 6. Carbuncle formation over the dorsum of the proxima
504 J. W. STRICKLAND

hemorrhagenic or purpuric lesions may result, with a gradual

crusting of the hemorrhagic areas and desquamation of the
involved epidermis occurring over several weeks. Immuno-
fluorescent titers of serum antibodies to herpes simplex antigens
may be helpful, and because the process is self-limiting, incision
and drainage procedures should be avoided.

Bites
Human or animal bites may result in the rapid onset of pain
and swelling in the area of innoculation with local erythema and
occasionally rapid spread. Human bites may result in infections
from Bacterium malaninogenicus, Staphylococcus aureus,
Micrococcus, Neisseria, spirochetes or even clostridia. Animal
bite infections are often from Pasteurella multocida. Treatment
should consist of adequate debridement with the wound left
open and soaks. The appropriate antibiotic may be gentamicin
plus either oxacillin or cephalothin. Complications from these
infections include tendon and joint destruction.

Erysipeloid
A rare infection following fish or meat handling is that
caused by Erysipelothrix rhusiopathiae (Rosenbach). The skin
usually exhibits a fairly well demarcated area of erythema,
which may be red or purple and may impart a shiny appearance
to the skin. Some swelling may be present and the area may be
slightly tender, but there is usually no significant pain. Itching is
a frequent complaint with this type of infection. No surgical
intervention is required in erysipeloid, and penicillin can usually
provide prompt relief.

Other Infections and Infection-Like

Lesions
Although less common, a number of other organisms may
produce hand infections, some of which are very difficult to
diagnose and recognize. Mycobacterium tuberculosis manifests
itself mainly at the wrist level and still remains an occasional
cause of severe synovial inflammation in the hand. Diagnostic
biopsy and synovectomy may be necessary and, on occasion,
the infected tendons will have to be removed as well. In earlier
stages management by antituberculous medication may be
HAND INFECTIONS 505

effective. Atypical acid-fast bacilli have also been implicated,

with Mycobacterium kansasii and marinum being the most
frequent. Special culture techniques will be necessary to
identify these organisms following biopsy, usually at the wrist
level.
The most frequent fungal infections in the hand are
manifest by the superficial abscesses of actinomycosis, the
linear appearance of erythematous, subcutaneous nodules in
sporotrichosis and the warty pustules of blastomycosis.
Gonorrhea may occasionally present in the hand in the form
of a suppurative arthritis or tenosynovitis. Pyogenic granuloma
is an unusual granulating lesion seen in the finger where tissue
excess above the skin line prevents epithelialization. Injection
injuries, insect bites, including the lesion produced by the
recluse spider, and occasional tumors may also mimic hand
infections.

Causes of Increased Severity

and Chronicity
The physician treating patients with hand infections should
be aware that systemic conditions may be responsible for some
infections and, in others, may mitigate strongly toward in-
creased severity. Diabetes mellitus, in particular, increases
susceptibility to infectious processes and makes their control
quite difficult.
One will occasionally encounter chronic hand infections
with persistent abscess formation or drainage which fails to
respond to the usual treatment modes. These chronic infections
may be simply secondary to inefficient drainage, or may result
from retained foreign bodies (Fig. 7), adherent tissue slough,
bony sequestrum, poor local blood supply, edema or some
other mechanical interference to healing.

Summary

An awareness of the characteristic presentation, etiologic

organisms and appropriate treatment of common hand infec-
tions is an important obligation of the primary care physician
and the hand surgeon. Recognition of more occult organisms,
such as M. tuberculosis, atypical acid-fast bacillus, or one of the
anaerobes or fungi, is also important if one is to institute the
506 J. W. STRICKLAND

FIG. 7. Chronic abscess secondary to retained foreign body. (A) Chronic

drainage over the third metacarpophalangeal joint following a fist fight and
several limited efforts at drainage. (B) The x-ray appearance of a retained
dental cap over the metacarpal neck, which served as a nidus for the
persistent abscess.
HAND INFECTIONS 507

correct treatment program. Failure to respond to an apparently

adequate treatment program after correct organism identifica-
tion may be secondary to local factors which prevent healing, or
to constitutional disease with lowered resistance. Despite the
lowered incidence of hand infections, it remains important to
promptly diagnose and treat these conditions before irreparable
functional damage results.

References

. Kanavel, A.B.: Infections of the Hand. London:Bailliere, Tindall and

Cox 1912:
. Kanavel, A.B.: Infections of the Hand, ed. 6. Philadelphia:Lee and
Febiger, 1933.
. Bailey, D.A.: The Infected Hand. London:H. K. Lewis & Co. Ltd,
1963.
. Sneddon, J.: The Care of Hand Infections. Baltimore:Williams &
Wilkins Co., 1970.
. Linscheid, R.L. and Dobyns, J.H.: Common and uncommon infec-
tions of the hand. Orthop. Clin. North Am. 6:1063-1104, 1975.
. Anderson, P.C.: Care of the hand: Neglected cutaneous disorders.
Orthop. Rev., April 1975, pp. 11-13.
Bolton, H., Fowler, P.J. and Jepson, R.P.: Natural history and
treatment of pulp space infection and osteomyelitis of the terminal
phalanx. J. Bone Joint Surg. [Br.] 31:499, 1949,
. Brown, H.: Hand infections. Am. Fam. Physician 18:79-85, 1978.
. Chuinard, R.G. and D’Ambrosia, R.D.: Human bite infections of the
hand. J. Bone Joint Surg. [Am.] 59:416-418, 1977.
. Clawson, D.K. and Dunn, A.W.: Management of common bacterial
infections of bones and joints. J. Bone Joint Surg. [Am. ] 49:164-182,
1967.
on
. Conklin, H.B., Curtis, R.M. and Ben-Efraim, S.: Koch’s phenomen
involving the flexor tendon sheath. J. Bone Joint Surg. [Am.]
51:1413-1419, 1969.
. Fitzgerald, R.H., Cooney, W.P. III, Washington, J.A. et al: Bacterial
. J. Hand
colonization of mutilating hand injuries and its treatment
Surg. 2:85-89, 1977.
hand. Surg.
. Flynn, J.E.: Acute suppurative tenosynovitis of the
Gynecol. Obstet. 76:227, 1943.
Incidence and
. Frazier, W.H., Miller, M., Fox, R.S. et al: Hand injuries:
1978.
epidemiology in an emergency service. JACEP 7:265-268,
J.A.: Geotric hum tumefac-
. Goldman, S., Lipscomb, P.R. and Ulrich,
the hand. J. Bone Joint Surg. [Am.] 51:587-5 90, 1969.
tion of
bite infections.
16. Goldstein, E.J.C., Caffee, H.H., Price, J. et al: Human
Lancet 1:290, 1977.
Hawkins, L.G.: Local Pasteurella multocida infections. J. Bone Joint
Li
Surg. [Am.] 51:363-366, 1969.
508 J. W. STRICKLAND

18. House, H.C. and Morris, D.: Bites of the hand. Md. State Med. J.
26:88-94, 1977.
19. Johnson, S.M. and Pankey, G.A.: Eikenella corrodens, osteomyelitis,
arthritis and cellulitis of the hand. South. Med. J. 69:535-539, 1976.
20. Kechavarz-Oliai, L.: Peripheral tuberculous lymphadenitis. Am. J. Dis.
Child. 122:74-75, 1971.
21. Kelly, P.J., Karlson, A.G., Weed, L.A. et al: Infection of synovial
tissues by mycobacteria other than mycobacterium tuberculosis. J.
Bone Joint Surg. [Am.] 49:1521-1530, 1967.
22. Kelly, P.J., Weed, A.G., Lipscomb, P.R. et al: Infection of tendon
sheaths, bursae, joints, and soft tissues by acid-fast bacilli other than
tubercle bacilli. J. Bone Joint Surg. [Am.] 45:327-336, 1963.
23. La Rossa, D. and Hamilton, R.: Herpes simplex infection of the
fingers. Mod. Med. 72:107, 1972.
24. Lowden, T.G.: Infections of the digital pulp space. Lancet 1:196,
OTe
25. Lowden, T.G.: Infections in clinical surgery. In Rob, C. and Smith, R.
(eds.): Operative Surgery. London: Butterworths, 1962, vol. 6, p. 156.
26. Lowden, T.G.: Prevention and treatment of hand infections. Br. Med.
J. 2:900, 1960.
27. MacFarlane, D.A., Murrell, J.S., Shooter, R.A. et al: Staphylococcal
sepsis in out-patients. Br. Med. J. 2:900, 1960.
28. Mann, R.J., Hoffeld, T.A. and Farmer, C.B.: Human bites of the
hand: Twenty years of experience. J. Hand Surg. Ze91-1045 OT Te
29. Mann, R.J.: Human bites can often lead to infection. JAMA
PST SINS AIL, UML.
30. Mock, H.E.: Treatment of hand infections from an economic
standpoint. Surg. Gynecol. Obstet. 21:481, 1915.
31. Pilcher, R.A., Dawson, R.L.G., Milstein, B.B. et al: Infections of the
fingers and hand. Lancet 1:777, 1948.
32. Price, D.J.E., O’Grady, F.W., Shooter, R.A. et al: Trial of phenoxy-
methyl penicillin, phenethicillin and lincomycin in treatment of
staphylococcal sepsis in a casualty department. Br. Med. J. 3:407,
1968.
33. Proceedings of the Section of Surgery, British Medical Association:
Discussion on the treatment of acute primary infections of the hand.
Br. Med. J. 2:1025, 1923.
34. Rein, J.M. and Cosman, B.: Bacteroids necrotizing fasciitis of the
upper extremity. Plast. Reconstr. Surg. 48:592-594, 1971.
35. Resnick, D.: Osteomyelititis and septic arthritis complicating hand
injuries and infections: Pathogenesis of roentgenographie abnormal-
ities. J. Can. Assoc. Radiol. 27:21-28, 1976.
36. Williams, E.M.: Wound infection following elective orthopedic pro-
cedures. South. Med. J. 61:497-500, 1968.
37. Williams, J.A., Meynell, M.J. and Watson, A.B.: Benethamine
penicil-
lin. A study of its use in a clinic for septic hands. Br. Med. J. 1:716,
1956.
38. Williams, R.E.O. and Miles, A.A.: Infections and sepsis
in industrial
wounds of the hand. Spec. Rep. Ser. Med. Rec. C, No. 266, 1949.
HAND INFECTIONS 509

Self-Evaluation Quiz

1. Which of the following organisms is rarely implicated in

infections of the hand?
a) Pseudomonas
b) Atypical mycobacteria
c) Staphylococci
d) Proteus
e) Streptococci
2. Which of the following supportive measures is currently felt
to have little value in the management of hand infections?
a) Rest
b) Elevation
c) Immobilization
a) Warm compresses
e) Hospitalization with intravenous antibiotics
3. Which of the following is not true about pulp abscess
(felon)?
a) Usually follows a puncture wound
b) Results in a hot, tender digital pulp
c) Is frequently secondary to staphylococcal infection
d) Is best managed by a midlateral drainage approach
e) Is characterized by a throbbing pain
4. The classical signs of Kanavel for acute suppurative teno-
synovitis include all of the following except:
a) Volar swelling
b) Pain with flexion
c) A position of digital flexion
d) Sheath tenderness
e) Pain with extension

Answers on page 527.

 Carroll Technique
of Small-Joint Arthrodesis
Joseph E. Imbriglia, M.D.

Objective
The purpose of this paper is to describe the indications
and techniques of performing arthrodesis of small joints.
s

Small-joint arthrodesis is performed in the hand for post-

traumatic, degenerative and paralytic conditions which result in
decreased function secondary to pain, instability or malposi-
tion. In osteoarthritis, the distal interphalangeal joints of the
fingers or the carpometacarpal joint of the thumb may require
arthrodesis. Patients with rheumatoid arthritis often require
arthrodesis of the proximal interphalangeal joints of the fingers
and the metacarpophalangeal joint of the thumb. In post-
traumatic or paralytic conditions, arthrodesis of an affected
joint may be necessary as an isolated procedure to increase
function, or as part of an overall reconstruction.
In the interphalangeal joint of the thumb and the distal
interphalangeal joints of the fingers, arthrodesis is the procedure
of choice for any of the conditions previously mentioned.
Arthroplasty or arthrodesis may be performed in the meta-
carpophalangeal and the proximal interphalangeal joints. The
choice of arthrodesis or arthroplasty in a particular patient is
dependent on numerous factors, including coexistent joint
disease, overall hand function, patient age and occupation. The
surgeon must decide in each particular case which procedure
will be of the most lasting benefit. Often in patients with

Joseph E. Imbriglia, M.D., Assistant Clinical Professor of Orthopedic

Surgery, University of Pittsburgh School of Medicine; Director, Hand
Clinic, Allegheny General Hospital, Pittsburgh, Pa.

511
Bly J. E. IMBRIGLIA

multiple joint involvement, arthodeses are combined with

arthroplasties to obtain optimal function (e.g. arthroplasty of
the metacarpophalangeal joint of the index finger, combined
with arthrodesis of the proximal interphalangeal joint in
rheumatoid arthritis).

Position of Arthrodesis

Figure 1 presents a general guide to the position of

arthrodesis in the finger and thumb. Radial digits are most
important for pinch, the ulnar digits for grasp; therefore, the
joints of the ulnar digits are arthrodesed in relatively more
flexion than the index finger. The distal interphalangeal joint of
the index finger is positioned in 10° to 20° of flexion, while the
distal interphalangeal joints of the ring and small fingers are
positioned in 25° of flexion. An arthrodesis of the proximal
interphalangeal joint of the index finger should be in 40° of
flexion. The degree of flexion increases in the ulnar digits, with

FIG. 1. (A) Position of arthrodesis at the metacarpophalangeal joint and

interphalangeal joint of the thumb. (B) Position of arthrodesis in the finger
joints. (From Carroll [1].)
SMALL-JOINT ARTHRODESIS SAILS

the proximal interphalangeal joint of the small finger being

fused in 50° of flexion. Occasionally, metacarpophalangeal joint
arthrodesis of the fingers is necessary. The index finger is
positioned in 25° of flexion at the metacarpophalangeal joint,
while the ulnar digits are placed in slightly more flexion.
The thumb interphalangeal joint is placed in 15° of flexion,
while the metacarpophalangeal joint of the thumb should be
positioned in 20° of flexion.
From a technical standpoint, the carpometacarpal joint of
the thumb is the most difficult to position properly. The proper
position is 40° to 45° of palmar abduction, with the pulp of the
thumb approaching the pulp of the index finger in 40° to 45°
of rotation. In addition to nonunions of attempted carpometa-
carpal joint arthrodeses, there can be severe problems with
malposition when this procedure is attempted (Fig. 2).

Technique

The distal interphalangeal and proximal interphalangeal

joints are approached through a dorsal incision. A gently curved

FIG. 2. An unacceptable position for arthrodesis of the trapeziometacarpal

joint. This patient required revision.
514 J. E. IMBRIGLIA

incision is preferable. The extensor mechanism is split longi-

tudinally and retracted to either side. The joint capsule is
excised, and the ligaments and periosteum are dissected off the
proximal aspect of the joint. This allows the proximal part of
the joint to be dislocated dorsally by flexion. The cartilage is
removed proximally, and the bone is fashioned into a spike,
saving as much medullary bone as possible. The distal portion of
the joint is then fashioned into a cone to accept the spike (Fig.
3). Once the bone has been prepared, the surfaces are coapted
to be sure of asnug fit. If the fit is satisfactory, the surfaces are
disengaged, the joint is flexed and a Kirschner wire is driven
distally down the medullary canal and brought out through the
skin. The wire is then withdrawn far enough distally to again
reduce the arthrodesis site. With the wire secure in the distal
fragment, the arthrodesis site is reduced into its proper position

Be
cS

FIG. 3. The cone and spike technique of arthrodesis. (From Carroll [1].)
SMALL-JOINT ARTHRODESIS 55

(Fig. 4). The Kirschner wire may then be driven from the distal
fragment into the proximal fragment, securing the arthrodesis.
The longitudinal wire may be left out of the skin or buried. I
generally leave the wire protruding from the skin, and remove
the wire in the office. An oblique transfixing wire or inter-
osseous wire suture may also be inserted (Fig. 5) if the
longitudinal wire does not provide enough stability. The deep
soft tissues and the extensor mechanism are reapproximated
with interrupted absorbable sutures, and the skin is closed.
Arthrodesis of the metacarpophalangeal joint is performed
in a similar fashion. The approach is dorsal, being careful to
avoid branches of the radial sensory nerve. The extensor hood is
split longitudinally through its radial aspect. Bone preparation
for these arthrodeses may be performed with a Hall drill or a
power saw.
In carpometacarpal joint arthrodesis (Fig. 6) the proximal
metacarpal is beveled and placed in a trough made in the
trapezium. This arthrodesis is also held with a longitudinal
Kirschner wire. I have generally performed these procedures
using a beveled, doubled-ended, 4-inch-long Kirschner wire on a
power drill.
Using this technique, Carroll and Hill [1, 2] reported a 5%
pseudoarthrosis rate in 635 joints. The distal joint had the
highest rate of pseudoarthrosis. The patients with the highest
rate of pseudoarthrosis were those with severe spasticity.
Healing of the arthrodesis takes between six and eight
for
weeks. External immobilization in a plaster splint is used
angeal and distal inter-
three weeks in the proximal interphal
is gen-
phalangeal joint fusions. The external immobilization
motion of the adjacent joints
erally removed after 21 days, and
are protecte d with tape and
is begun. The exposed pins
except when the patient is
individual finger splints are worn,
are removed between six and
exercising. The Kirschner wires
the clinical and
eight weeks after surgery, depending on both
Arthrode ses of the thumb
radiographic evidence of healing.
eal joints are immobilized
interphalangeal and metacarpophalang
in a thumb spica cast for a period of six weeks.
s: (1) a large
The advantages of this technique are as follow
t, (2) intrin sic stabil ity of the
area of medullary bone contac
the abilit y to adjust rotati on of the
coapted bone surfaces, (3)
 516 J. E. IMBRIGLIA

FIG. 4. Postoperative radiograph of a proxima

l interphalangeal joint
arthrodesis with the fixation wire in position.
SMALL-JOINT ARTHRODESIS 517

sseous wire in position in an

FIG. 5. Longitudinal wire and intero
arthrodesis of a distal interphalangeal joint.
518 J. E. IMBRIGLIA

FIG. 6. Technique of trapeziometacarpal arthrodesis.

SMALL-JOINT ARTHRODESIS 519

arthrodesis site after the longitudinal wire is inserted, as well as

the ability to impact the arthrodesis after the longitudinal wire
is inserted, and (4) easy removal of the Kirschner wires in the
office.

References

1. Carroll, R.E. and Hill, N.A.: Small joint arthrodesis and hand
reconstruction. J. Bone Joint Surg. 51A:12-19, 1969.
2. Carroll, R.E. and Hill, N.A.: Arthodesis of the carpometacarpal joint of
the thumb. J. Bone Joint Surg. 55B:292, 1973.

Editor’s Note:

I would like to share with the readers some techniques that

I have learned that make the Carroll small-joint arthrodesis an
extremely effective and reliable procedure.
Compression is an essential aspect of the arthrodesis. It may
very well account for the high fusion rate. After the longi-
tudinal K wire is inserted, when the two bones are joined
together, they are very tightly compressed with pressure along
their longitudinal axis. A second and third crossed K wire can
be added or they can be left with the one longitudinal K wire.
The additional K wires are particularly useful at the DIP joint of
a finger or the IP joint of the thumb to give maximum stability.
When the arthrodesis is done following excision of a ruptured
profundus tendon in the palm, I usually begin immediate
motion of the finger. In this event, it is extremely useful to have
the two crossed K wires supplementing the longitudinal one
since there is no external support. When I do use three pins, I
usually remove either the two cross ones or the single
longitudinal one at the six-week mark if there is good healing,
the
and then the others, one or two weeks later. This allows
arthrodesis to develop with gradual stress at the fusion site.
Finally, a comment on the actual technique of shaping the
through
bone. I usually use a power drill to make multiple holes
n at the base of the phalanx at a 45°
the osteochondral junctio
axis. These are then joined with an
angle to the longitudinal
the phalanx is remove d in one piece.
osteotome, and the base of
an excessive
This avoids the use of a burr, which would cause
of heat and might cause cell damage. This also
amount
that one might acciden tally burr through
eliminates the chance
 520 J. E. IMBRIGLIA

the cortex of the bone just below the joint line. When
fashioning the distal end of the other bone, I make a point of
removing the condyles first and making a cylinder before
further shaping it into a spike.
With the help of these additional techniques, my fusion rate
has been in excess of 98% in a rather large series, many of which
have been subjected to very early motion.

Self-Evaluation Quiz

Small-joint arthrodesis as an isolated procedure is most

likely to be required in:
a) Posttraumatic conditions
b) Osteoarthritis
c) Rheumatoid arthritis
d) Paralytic conditions
In the interphalangeal joint of the thumb and _ distal
interphalangeal joints of the fingers ____————_—ig the
procedure of choice:
a) Arthroplasty
b) Arthrodesis
Ulnar digits are most important in pinch and radial digits in
grasp.
a) True
b) False
Joints of the ulnar digits are arthrodesed in greater flexion
than the index finger.
_a) True
b) False
a Healing of the arthrodesis takes six to eight weeks.
a) True
b) False

Answers on page 527.

 Medicolegal Update

J. Joseph Danyo, M.D.

Objective
Every surgeon is touched by the medicolegal implica-
tions of the treatment he provides. Presented here are some
basic concepts and precepts about how hospital regulations
in the medicolegal area have changed and how they directly
» affect the surgeon. Three typical examples illustrate what is
going on in hospital medicolegal circles today.

At one time, hospitals enjoyed a unique status. They had

what was called charitable immunity, which meant that,
whatever happened to a patient, the hospital was not held
liable. Hospitals were prevented from being sued because of this
doctrine. Nevertheless, the courts ruled that if a patient is
injured, he cannot be uncompensated. As a result, the “‘captain-
of-the-ship” doctrine was created. In other words, somebody
had to be responsible. The ‘“‘captain” was the doctor. So
regardless of the circumstance, the doctor was adjudged
negligent and he or his insurance company would have to pay.
But it was not that simple. Remember that nurses also take
care of patients: they do massage, give injections, monitor
to
bodily functions and perform various other tasks. In order
of the ship all-enc ompassi ng,
make the doctrine of the captain
In
the courts hit upon the borrowed-servant or lent-servant idea.
if a nurse gave an injectio n
the days of charitable immunity,
hospital could not be held liable,
into the sciatic nerve, since the
borrowed-
the patient’s physician was held liable. Under the
e, this merely meant that, for
servant or lent-servant principl
physicia n’s patients , the hospital
purposes of taking care of a

dics, York Hospital,

J. Joseph Danyo, M.D., F.A.C.S., Chief of Orthope
York, Penn.

521
 D2 J.J. DANYO

lent one of its employees to him and therefore it had no

responsibility.
Today in the United States, charitable immunity no longer
exists. Consequently, hospitals have taken upon themselves or
have been pushed into accepting liability or responsibility for
their actions. What does this mean? It means that in half of the
50 states, we do not have the true captain-of-the-ship doctrine
that was prevalent in the days of charitable immunity. Even in
those states where this doctrine is still valid, it does not
necessarily mean that anything that goes wrong with a patient is
directly attributable to the physician. In the 25 states where the
captain-of-the-ship doctrine has been torpedoed, it is held that,
if a nurse making a sponge count has erred, the surgeon will not
be responsible or held liable for that incident. The hospital and
the nurse will assume total liability. In states where the doctrine
has been only slightly modified, it may mean that the doctor
and the hospital can be held jointly liable. But certainly, the
hospital cannot escape its liability. In an instance of sciatic
nerve injection, both the nurse and the doctor will be held
hable.
What it all amounts to is this: Hospitals have assumed more
liability. Phsyicians have assumed less responsibility. Because
the hospitals have assumed more responsibility, they must do
something to protect their rear guard. That ‘“‘something”’ is what
will be discussed in three important legal cases.
The first one is the case of Darling vs. Charleston Memorial
Hospital. This was a 1958 case that involved an orthopedic
surgeon who put on a tight cast. The assisting nurse told him
that the cast was too tight. He ignored her. Finally, a stench
developed and an anaerobic infection was noted. Following an
amputation, the patient sued the doctor, the nurse and the
hospital. The hospital said: “Now wait just a minute! This
fellow was just working there and we are sort of like a hotel. We
have no responsibility.’ The nurse said: ‘“‘ I was only doing what
the doctor told me to do.” The court ruled that there was a
corporate responsibility or corporate liability; that is,
the
hospital via the nurse (its employee) should have done
something to actively intervene. She knew that an infection was
present, regardless of what the doctor told her. She had
the
responsibility to serve the hsopital, since she was paid
by the
MEDICOLEGAL UPDATE oZ3

hospital, by reporting the facts to the chief of service or the

administrator or to somebody in the hospital. But she had to
actively intervene. Because she failed to do so, both she and the
hospital were liable — not for Dr. Darling’s negligence, but for
the negligence in not reporting to the proper authorities in time.
Darling vs. Charleston Memorial Hospital has been a nation-
al case in the sense that virtually all states have adopted this
concept, even though it was a middle-America case; i.e., it was
not decided in a federal court. So we now have the corporate
liability doctrine, and because of this, hospitals have had to put
the squeeze on physicians.
A second important case is that of John Nork vs. Mercy
Hospital, which was decided in California in the early 1970s.
Dr. Nork was a very innovative person. Toward that end, he
seemed to concoct histories, physicals and laboratory data to
substantiate his treatment. He tended to interpret myelograms
in ways that differed from the radiologist’s opinions. As a
result, he did a fair amount of disc surgery. At two hospitals in
the Sacramento area, he was released from the staff. He then
went to Mercy Hospital in Sacramento. Several members of the
credentials committee of the hospital knew Dr. Nork’s past
record but did nothing about it. Dr. Nork began doing surgery
at Mercy Hospital. He had one patient with back pain who
developed a cord problem with bowel and bladder dysfunction.
Allegedly, the patient later became an alcoholic, a wife and
child abuser, and died of metastatic disease of the bone. The
wife sued Dr. Nork and the hospital. The court held that
doctors serving on a credentials committee not only are
responsible to the medical staff, but also they are indeed acting
as employees of the hospital and of the hospital board when
they function as a credentials committee. Therefore, Mercy
Hospital was held liable for the fact that its credentials
sense
committee knew Dr. Nork’s capabilities. They knew in a
— but they
that he was a “‘bad apple’? — an impaired physician
prevent his
did nothing about it. Because of their failure to
occupying a position of trust in the hospital, Mercy Hospital
was held liable.
What does all of that forbode for other surgeons? It means
take great
that hospitals, via their credentials process, must
on staffs. They
pains to see that “bad apples” do not get placed
 524 J.J. DANYO

must monitor doctors on a yearly basis, not only as to their

professional conduct but also their ethical, social and moral
behavior as well, both in and out of the hospital. If something
of an untoward nature comes up and the recredentialing process
does not address the situation, both the hospital and the
credentials committee can be held liable, and the board of
trustees can be held accountable as well.
A third interesting case occurred in New Jersey. This was
the Corletto case, which was unusual because in it an
entire
medical staff was sued. A young woman had acute appendicitis.
The general surgeon caring for this patient was allegedly past
his
prime both mentally and physically; he could not use his hands
in his profession as he had formerly been able. Many of
the
members of the staff knew about this. He thought the patient
had ileitis and as an emergency procedure did a bowel resectio
n.
The appendix perforated; peritonitis and death ensued.
The
family sued the doctor, the hospital, the nurses who
had
worked with the patient and every one of the 141 member
s of
the staff of the hospital. The outcome was simply
this: The
court told the family that if they could prove that
any or all of
the staff members of the hospital had any knowled
ge of this
doctor’s impairment, then each or all of those physicia
ns could
be held personally liable for failing to report
and to take
appropriate action. Several physicians, the medical
staff and the
hospital agreed to a settlement of the case;
so there was no
formal situation where a court adjudication was
handed down.
But the mere fact that the case was settled
in favor of the
plaintiff indicates the weight of the law in this respect.
Today in most hospitals there is a recredential
ing procedure;
that is, a staff appointment is made for one
to three years, and
then it must be reviewed through some
mechanism. This
mechanism is looked at by the Joint
Commission on the
Accreditation of Hospitals upon its inspection.
Another aspect of this case has to do with
the role of the
nurse and the therapist in the hospital.
Some surgeons have
been bewildered of late to see nurses writing
admission notes on
patient charts. There is an admission plan.
There may even be
an admission history and physical done
by the nurses. The
courts have recognized that a doctor canno
t be available all of
the time, including the time of the admission
of his patient: He
MEDICOLEGAL UPDATE 525

might be in his office. He might be out of town. It might be an

elective admission not requiring his immediate presence. But
they have also decreed that an admission note must be filed.
Nurses are health care providers; therefore, they must come up
with a health care plan. They have to assess the patient, state
what is wrong with him, describe what the patient has told
them, indicate that the patient understands the proposed
surgery and outline a nursing plan. The courts have further
stated that if other nurses disagree with that nursing plan, they
must call the physician and discuss with him the patient’s
situation. If the physician refuses to discuss it or his answer
seems inappropriate, then the nurse is to actively intervene by
notifying the hospital administration.
Furthermore, regarding medication, it has been recognized
that the physician often does not know all of the side effects
and interactions of various medications, and some of this
responsibility has been given to the nurse. If she gives
medications that have an adverse interaction, then the nurse,
the physician and the hospital can be held liable. So we see that
nurses have accumulated an increased liability, being agents or
servants of the hospital, while the captain-of-the-ship doc-
trine has diminished. Still, hospitals are trying to transfer as
much of the liability as possible to the physicians.
One final point should be made: Based on a review of
several hundred cases, the sine qua non of the average medical
malpractice suit is poor documentation, poor records. It is not
schooling, or surgery done on the wrong part or the retained
sponge. It is poor recordkeeping. Legally, if the doctor does not
notate appropriately, it means that whatever is claimed did not
happen. Now it is a footrace, a credibility game, between the
patient (or plaintiff) and the doctor (or defendant). A good,
that if
astute plaintiff’s lawyer is going to bring out the “fact’’
did not
the doctor does not have something in his records, it
says it
occur. The patient says it did not happen, and the doctor
did happen; so now a jury must decide who to believe.
Therefore, more perfect, more timely progress notes are
progress note. If
imperative. Whatever you do, do not change a
study incorrectly or
you have either interpreted a laboratory
leave it; draw a
dictated a wrong note in the operating room,
at the bottom write,
line through it so that it is still legible and
 526 J. J. DANYO

“in the record room at the time of discharge summary,’ put in

an addendum and note the current date. If it is three months

what really happened: ....’? You may be held negligent. A jury

may not believe you. But at least if you are hauled into court,
the jury will not think you are a crook. They realize that
doctors are busy ard may not have a chance to look at all of the
possibilities, but may later recognize an error and record it. If
you keep sloppy records, the indication is that you give sloppy
care. So by all means, your biggest offense is the record. Use it,
instead, as your greatest defense.

Self-Evaluation Quiz
1. Under the charitable immunity concept an institution could
not be penalized for the actions of a nurse but could be held
liable for the actions of a staff physician.
a) True
b) False
2. A nurse who states an objection to a course of treatme
nt or
observation of his error to the attending physician has
discharged her full responsibility.
a) True
b) False
3. A physician may be held liable for the actions of
another
physician if he has prior knowledge of the former’
s
impairment of any kind.
a) True
b) False
4. In the administration of medications with
adverse inter-
actions, the nurse, physician and hospital can
all be held
liable.
a) True
b) False

Answers on page 527.

Answers to Self-Evaluation Quizzes

Page 8: 1(f); 2 (a); 3 (b); 4 (£); 5 (d); 6 (b); 7 (e).

Page 24: 1 (b); 2 (b); 3 (b); 4 (b); 5 (b); 6 (c,d); 7 (a); 8
(b,c,d,a).

Page 34: 1 (a); 2 (b); 3 (a); 4 (a); 5 (b); 6 (a); 7 (a); 8 (a); 9
(b); 10 (a).
Page 50: 1 (a); 2 (b); 3 (b); 4 (a); 5 (b); 6 (a,d); 7 (a); 8 (b).

Page 66: 1 (c); 2 (b,d,e); 3 (a); 4 (a); 5 (c); 6 (b); 7 (a).

Page 77: 1 (a); 2 (a); 3 (b); 4 (a); 5 (b); 6 (a); 7 (b).

Page 90: 1 (b); 2 (b); 3 (a); 4 (a); 5 (a); 6 (a); 7 (a); 8 (b); 9
(b); 10 (b).
Page 100: 1 (d); 2 (b); 3 (b); 4 (b); 5 (b).
Page 109: 1 (a); 2 (a); 3 (d); 4 (c); 5 (b); 6 (e,b,a,c,8,£,d); 7
(b); 8 (a,b,c).
Page 120: 1 (a); 2 (a); 3 (b); 4 (a); 5 (b); 6 (b); 7 (a); 8 (b); 9
(a); 10 (a).
Page 129: 1 (a); 2 (b); 3 (a); 4 (a); 5 (b); 6 (b); 7 (a); 8 (b); 9
(b);10 (a).
Page 138: 1 (e); 2 (a); 3 (a); 4 (b); 5 (a); 6 (c,d); 7 (c); 8 (b);
9 (e); 10 (a); 11 (b); 12 (a).

Page 171: 1 (b); 2 (c); 3 (b); 4 (c); 5 (e)5 6 (b); 7 (b).

Page 204: 1 (b); 2 (b); 3 (b); 4 (a); 5 (b); 6 (a); 7 (a); 8 (b).

527
 528 ANSWERS

Page 213: 1 (e); 2 (a); 3 (a); 4 (b); 5 (a); 6 (c); 7 (c); 8 (a); 9
(c); 10 (a).
Page 223: 1 (b,e); 2 (a); 3 (d); 4 (d); 5 (b); 6 (c).
Page 229: 1 (d); 2 (b); 3 (e); 4 (d).
Page 233: 1 (b); 2 (b); 3 (b); 4 (a); 5 (a); 6 (a); 7 (b); 8 (a).
Page 238: 1 (a); 2 (a,b,c,d); 3 (b); 4 (a); 5 (a,b,c,d); 6 (b); 7
(c); 8 (a,b).

Page 246: 1 (f); 2 (b); 3 (d); 4 (d); 5 (b); 6 (b); 7 (b); 8 (c); 9
(c); 10 (f).
Page 259: 1 (c); 2 (c); 3 (e); 4 (d); 5 (a); 6 (b); 7 (a); 8 (a).
Page 265: 1 (b); 2 (a); 3 (e); 4 (b); 5 (b).
Page 278: 1 (a); 2 (b); 3 (a); 4 (b); 5 (b); 6 (a); 7 (a).
Page 293: 1 (b); 2 (b); 3 (c); 4 (d); 5 (a); 6 (a); 7 (c); 8 (A); 9
(b).
Page 308: 1 (b); 2 (a); 3 (c); 4 (d).
Page 313: 1 (b); 2 (b); 3 (a); 4 (b); 5 (b); 6 (a); 7 (b); 8 (b).
Page 327: 1 (c); 2 (b); 3 (d); 4 (e).
Page 353: 1 (b); 2 (b); 3 (c); 4 (a); 5 (a); 6 (a); 7 (a,c,e).
Page 361: 1 (e); 2 (d); 3 (c); 4 (d); 5 (b); 6 (b); 7 (b); 8 (b).
Page 371: I (c); 2 (a); 3 (e); 4 (a); 5 (c); 6 (£); 7 (A); 8 (b); 9
(a,b,c); 10 (a,b,c).

Page 375: 1 (ad); 2 (c); 3 (b).

Page 393: 1 (b); 2 (c); 3 (a); 4 (b ); 5 (a); 6 (c); 7 (a,c); 8 (c); 9
(b); 10 (a).
ANSWERS 529

Page 406: 1 (c); 2 (c);3 (a); 4 (b); 5 (a).

Page 425: 1 (b); 2 (b); 3 (a); 4 (a); 5 (b); 6 (a); 7 (a); 8 (b); 9
(b); 10 (a).
Page 456: 1 (a); 2 (b); 3 (e); 4 (b); 5 (b); 6 (b); 7 (a); 8 (a); 9
(c,d). 10 Ta)e114b); 12 (a):

Page 478: 1 (b); 2 (a); 3 (a); 4 (a); 5 (b); 6 (b); 7 (a); 8 (a); 9
(b); 10 (b).
Page 490: 1 (b); 2 (a); 3 (a); 4 (b); 5 (a); 6 (b).

Page 509: 1 (b); 2 (a); 3 (a); 4 (b).

Page 520: 1 (a,d); 2 (b); 3 (b); 4 (a); 5 (a).
Page 526: 1 (b); 2 (b); 3 (a); 4 (a).
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 Dahlgren Memorial Library
Center
Georgetown University Medical
$900 Reservoir Road, N.W.
Washington, D. 6. 20007
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